Provider Demographics
NPI:1700197365
Name:SAMIR A SHAH MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SAMIR A SHAH MD PROFESSIONAL CORPORATION
Other - Org Name:BEACH EYE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-965-9696
Mailing Address - Street 1:18582 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1701
Mailing Address - Country:US
Mailing Address - Phone:714-965-9696
Mailing Address - Fax:714-965-9797
Practice Address - Street 1:18582 MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1701
Practice Address - Country:US
Practice Address - Phone:714-965-9696
Practice Address - Fax:714-965-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
CAA85961207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty