Provider Demographics
NPI:1508196759
Name:HIGH DESERT NEPHROLOGY MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:HIGH DESERT NEPHROLOGY MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:ERIAH
Authorized Official - Last Name:SHANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-241-3306
Mailing Address - Street 1:12675 HESPERIA RD.
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5878
Mailing Address - Country:US
Mailing Address - Phone:760-241-3306
Mailing Address - Fax:760-241-8063
Practice Address - Street 1:655 S. 7TH AVE.
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3001
Practice Address - Country:US
Practice Address - Phone:760-256-3918
Practice Address - Fax:760-256-5217
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGH DESERT NEPHROLOGY MEDICAL ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-12
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508196759Medicaid
CA1508196759Medicaid