Provider Demographics
NPI:1245698752
Name:SHANTHIMD DERMATOLOGY, INC.
Entity type:Organization
Organization Name:SHANTHIMD DERMATOLOGY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANTHI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COLACO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-421-4747
Mailing Address - Street 1:2990 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-0002
Mailing Address - Country:US
Mailing Address - Phone:323-421-4747
Mailing Address - Fax:949-955-7351
Practice Address - Street 1:2990 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-0002
Practice Address - Country:US
Practice Address - Phone:323-421-4747
Practice Address - Fax:949-955-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123314207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB250969Medicare PIN