Provider Demographics
NPI:1700891520
Name:SHAHANI, PUSHPA HIRO (MD)
Entity type:Individual
Prefix:
First Name:PUSHPA
Middle Name:HIRO
Last Name:SHAHANI
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 1:225 S LAKE AVE
Mailing Address - Street 2:535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:1812 VERDUGO BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1407
Practice Address - Country:US
Practice Address - Phone:818-952-2214
Practice Address - Fax:818-952-4618
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32555207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325550OtherBLUE SHIELD
CA00A325550Medicaid
A26844Medicare UPIN
CAWA32555CMedicare ID - Type Unspecified
CA00A325550Medicaid
CA00A325550OtherBLUE SHIELD