Provider Demographics
NPI:1811913221
Name:SHAHAN, FRED F (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:F
Last Name:SHAHAN
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 1:6367 ALVARADO CT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4904
Mailing Address - Country:US
Mailing Address - Phone:619-287-1882
Mailing Address - Fax:619-287-4121
Practice Address - Street 1:6367 ALVARADO CT
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4904
Practice Address - Country:US
Practice Address - Phone:619-287-1882
Practice Address - Fax:619-287-4121
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG83901207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG83901BMedicare ID - Type Unspecified
CAWG83901HMedicare ID - Type Unspecified
CAWG83901CMedicare ID - Type Unspecified
CAWG83901FMedicare PIN
CAG19221Medicare UPIN
CAWG83901DMedicare ID - Type Unspecified
CA00G839011Medicare ID - Type Unspecified