Provider Demographics
NPI:1760553812
Name:SHIDYAK, GHASSAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:GHASSAN
Middle Name:E
Last Name:SHIDYAK
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 1:1260 EAST AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1021
Mailing Address - Country:US
Mailing Address - Phone:530-898-8088
Mailing Address - Fax:
Practice Address - Street 1:1531 ESPLANADE STE 130
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-332-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8996207L00000X
CAC55462207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11906Medicaid
ND11906Medicaid
CAP01650923Medicare PIN
CACA166496Medicare PIN