Provider Demographics
NPI:1740375088
Name:SHILYANSKY, ETEMA (MD)
Entity type:Individual
Prefix:DR
First Name:ETEMA
Middle Name:
Last Name:SHILYANSKY
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 1:803 WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1428
Mailing Address - Country:US
Mailing Address - Phone:626-793-3761
Mailing Address - Fax:626-449-5063
Practice Address - Street 1:416 W LAS TUNAS DR
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1236
Practice Address - Country:US
Practice Address - Phone:626-308-9220
Practice Address - Fax:626-308-9460
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD72103Medicare UPIN
CAA37752Medicare ID - Type Unspecified