Provider Demographics
NPI:1679592463
Name:SHAH, SHASHI K (MD)
Entity type:Individual
Prefix:DR
First Name:SHASHI
Middle Name:K
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 1:600 N MOUNTAIN AVE
Mailing Address - Street 2:SUITE#D100
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4359
Mailing Address - Country:US
Mailing Address - Phone:909-946-2828
Mailing Address - Fax:909-946-4288
Practice Address - Street 1:600 N MOUNTAIN AVE
Practice Address - Street 2:SUITE#D100
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4359
Practice Address - Country:US
Practice Address - Phone:909-946-2828
Practice Address - Fax:909-946-4288
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330692325OtherTAX ID
CA00A489530Medicare ID - Type UnspecifiedPROVIDER NUMBER
CAF23807Medicare UPIN