Basic Information
| Provider Information | |||||||||
| NPI: | 1013245950 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHOPTAW | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103194700 | ||||||||
| FaxNumber: | 3102060209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1920 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904043414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103194700 | ||||||||
| FaxNumber: | 3102060209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2009 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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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 | 103TC0700X | PSY13300 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1013245950 | 05 | CA | MEDICAID |