Provider Demographics
NPI:1811000573
Name:BRADY, SHAWN K (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:K
Last Name:BRADY
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:P.O. BOX 11949
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1949
Mailing Address - Country:US
Mailing Address - Phone:800-513-5332
Mailing Address - Fax:
Practice Address - Street 1:200 MISSION BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2564
Practice Address - Country:US
Practice Address - Phone:209-223-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52057207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A520570Medicaid
CA00A520571Medicare PIN
CA00A520570Medicaid