Basic Information
| Provider Information | |||||||||
| NPI: | 1245245018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHALI | ||||||||
| FirstName: | REYZAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1926 VIA CTR | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920816056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609407000 | ||||||||
| FaxNumber: | 7609400042 | ||||||||
| Practice Location | |||||||||
| Address1: | 6185 PASEO DEL NORTE STE 100 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609407000 | ||||||||
| FaxNumber: | 7609400042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A76230 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A762300 | 05 | CA | MEDICAID |