Provider Demographics
NPI:1639307895
Name:SCARBROUGH, SHANICKA N (MD)
Entity type:Individual
Prefix:DR
First Name:SHANICKA
Middle Name:N
Last Name:SCARBROUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANICKA
Other - Middle Name:N
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 221788
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-8788
Mailing Address - Country:US
Mailing Address - Phone:312-722-2683
Mailing Address - Fax:312-275-7549
Practice Address - Street 1:3746 FOOTHILL BLVD # B140
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91214-1740
Practice Address - Country:US
Practice Address - Phone:310-445-5999
Practice Address - Fax:323-544-4248
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144347207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128645Medicaid
IL036128645Medicaid