Basic Information
| Provider Information | |||||||||
| NPI: | 1356787840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SAMAD | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SHAH | ||||||||
| OtherFirstName: | SAMAD | ||||||||
| OtherMiddleName: | SYED | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 31309 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900310309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234428541 | ||||||||
| FaxNumber: | 3234428755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SAN PABLO ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234428541 | ||||||||
| FaxNumber: | 3234428755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2013 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | A154744 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.