Provider Demographics
NPI:1952518763
Name:SHASHI K. SHAH M D INC
Entity Type:Organization
Organization Name:SHASHI K. SHAH M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHASHI
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-946-2828
Mailing Address - Street 1:600 N MOUNTAIN AVE
Mailing Address - Street 2:SUITE D100
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4359
Mailing Address - Country:US
Mailing Address - Phone:909-946-2828
Mailing Address - Fax:909-946-4288
Practice Address - Street 1:600 N MOUNTAIN AVE
Practice Address - Street 2:SUITE D100
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4359
Practice Address - Country:US
Practice Address - Phone:909-946-2828
Practice Address - Fax:909-946-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9599928Medicaid
CA1679592463Medicare PIN
CAF23807Medicare UPIN
CA9599928Medicaid