Basic Information
| Provider Information | |||||||||
| NPI: | 1154645398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAMSHEED JAMES SHAMLOO MD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MT. VERNON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1023 S MOUNT VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923244202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094228015 | ||||||||
| FaxNumber: | 9094220625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1023 S MOUNT VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923244202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094228015 | ||||||||
| FaxNumber: | 9094220625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2010 | ||||||||
| LastUpdateDate: | 06/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHAMLOO | ||||||||
| AuthorizedOfficialFirstName: | JAMSHEED | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9094228015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A89604 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 8440339 | 05 | CA | MEDICAID |