Provider Demographics
NPI:1720043268
Name:SHAPIRO, DESMOND (MD)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 CIRCADIAN WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5416
Mailing Address - Country:US
Mailing Address - Phone:707-526-2027
Mailing Address - Fax:707-526-2096
Practice Address - Street 1:2301 CIRCADIAN WAY
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5416
Practice Address - Country:US
Practice Address - Phone:707-526-2027
Practice Address - Fax:707-526-2096
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26474174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26474OtherLICENSE
CA00A264740Medicaid
00A264740Medicare PIN
ZZZ25299ZMedicare PIN
CAA26474OtherLICENSE
CA00A264740Medicaid