Provider Demographics
NPI:1912068271
Name:DEWAR, SHANTI L (MD)
Entity Type:Individual
Prefix:
First Name:SHANTI
Middle Name:L
Last Name:DEWAR
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 1:399 E HIGHLAND AVE SUITE 124
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404
Mailing Address - Country:US
Mailing Address - Phone:909-886-6576
Mailing Address - Fax:909-882-1299
Practice Address - Street 1:399 E HIGHLAND AVE SUITE 124
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-886-6576
Practice Address - Fax:909-882-1299
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A33701Medicaid
A27223Medicare UPIN
CA00A33701Medicare ID - Type Unspecified