Provider Demographics
NPI:1790882959
Name:SHAH, CHUNILAL GANGJI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUNILAL
Middle Name:GANGJI
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 1:11530 LA MIRADA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1162
Mailing Address - Country:US
Mailing Address - Phone:562-947-1619
Mailing Address - Fax:562-947-5969
Practice Address - Street 1:11530 LA MIRADA BLVD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1162
Practice Address - Country:US
Practice Address - Phone:562-947-1619
Practice Address - Fax:562-947-5969
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33116208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A331160Medicaid
A84430Medicare ID - Type Unspecified
CA00A331160Medicaid