Provider Demographics
NPI:1255349379
Name:SHAH, SMITA JAYPRAKASH (MD)
Entity type:Individual
Prefix:
First Name:SMITA
Middle Name:JAYPRAKASH
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 BRADLEY ST
Mailing Address - Street 2:STE 120
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:770-701-6655
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:909-887-9565
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40709207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A407090Medicaid
CA00A407090OtherBLUE SHIELD
CAA40709Medicare PIN
CA00A407090Medicaid