Basic Information
| Provider Information | |||||||||
| NPI: | 1134376080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LADSON | ||||||||
| FirstName: | SHELESTE | ||||||||
| MiddleName: | VERENA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11234 ANDERSON ST RM 21005 CP | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92354 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST RM 21005 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A114245 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | A114245 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 05 | OH | MEDICAID |