Basic Information
Provider Information | |||||||||
NPI: | 1013995737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEN | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 516588 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900510598 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026716406 | ||||||||
FaxNumber: | 7028954014 | ||||||||
Practice Location | |||||||||
Address1: | 1707 W CHARLESTON BLVD STE 160 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891022354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026715150 | ||||||||
FaxNumber: | 7023846493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2006 | ||||||||
LastUpdateDate: | 02/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | 9317 | NV | Y |   | Allopathic & Osteopathic Physicians | Transplant Surgery |   |
ID Information
ID | Type | State | Issuer | Description | BS2203367 | 01 | NV | DEA | OTHER | V52007 | 01 | NV | PTAN | OTHER | CS09763 | 01 | NV | PHARMACY/CDS | OTHER | 1013995737 | 05 | NV |   | MEDICAID |