Provider Demographics
NPI:1972827806
Name:SHETABI, KAMBIZ (MD)
Entity Type:Individual
Prefix:
First Name:KAMBIZ
Middle Name:
Last Name:SHETABI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:591 TELEGRAPH CANYON RD # 766
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6436
Mailing Address - Country:US
Mailing Address - Phone:619-434-4288
Mailing Address - Fax:619-434-4315
Practice Address - Street 1:1415 E 8TH ST STE 7
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2663
Practice Address - Country:US
Practice Address - Phone:619-434-4288
Practice Address - Fax:619-434-4315
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI56405207RC0000X
CAA126187207RC0000X, 207RI0011X
TXR8102207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA126187OtherCA MEDICAL BOARD
TXR8102OtherTEXAS MEDICAL BOARD