Provider Demographics
NPI:1942246111
Name:SHIDBAN, HAMID (MD)
Entity Type:Individual
Prefix:DR
First Name:HAMID
Middle Name:
Last Name:SHIDBAN
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5908
Mailing Address - Fax:
Practice Address - Street 1:1516 SAN PABLO ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-5908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48781204F00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A487810OtherCCS
CAA48781OtherLICENCE NO
CA00A487810Medicaid
CA05D0726009OtherCLIA
CABS2896150OtherDEA
CAA48781OtherLICENCE NO
CAWA48781EMedicare ID - Type UnspecifiedMEDICARE
CAWA48781FMedicare ID - Type UnspecifiedSAN DIEGO, AREA 99
CAWA48781GMedicare ID - Type UnspecifiedSAN LUIS OBISPO
CAA48781OtherLICENCE NO
CA00A487810Medicaid