Provider Demographics
NPI:1679613368
Name:SHAH, PRAVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVIN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3567
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-8567
Mailing Address - Country:US
Mailing Address - Phone:949-764-8123
Mailing Address - Fax:
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-8123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC37705174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC37705OtherMEDICAL LICENSE
11420405OtherSOCIAL SECURITY NUMBER
CAAS066602OtherDEA
CAAS066602OtherDEA