Provider Demographics
NPI:1922296854
Name:SHAHLA P RAHMATULLAH M.D. INC
Entity Type:Organization
Organization Name:SHAHLA P RAHMATULLAH M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:P
Authorized Official - Last Name:RAHMATULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-653-1300
Mailing Address - Street 1:351 OLD NEWPORT BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4120
Mailing Address - Country:US
Mailing Address - Phone:949-653-1300
Mailing Address - Fax:949-353-1311
Practice Address - Street 1:4870 BARRANCA PKWY STE 230
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4788
Practice Address - Country:US
Practice Address - Phone:949-653-1300
Practice Address - Fax:949-653-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C519930261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C519930Medicaid
CAAY860Medicare PIN
CA00C519930Medicare PIN