Basic Information
| Provider Information | |||||||||
| NPI: | 1518340058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAM | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 975 SERENO DR | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259151362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3231 EUCLID AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087832000 | ||||||||
| FaxNumber: | 7087833656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2015 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125070732 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18473 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.