Basic Information
| Provider Information | |||||||||
| NPI: | 1568435717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHU | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 SITUS CT | ||||||||
| Address2: | STE 170 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276064279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198342767 | ||||||||
| FaxNumber: | 9198340234 | ||||||||
| Practice Location | |||||||||
| Address1: | 8599 HAVEN AVE. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096208180 | ||||||||
| FaxNumber: | 9099197288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A70061 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2006-01622 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A700610 | 05 | CA | MEDICAID | CG1263 | 01 | CA | RAILROAD MEDICARE | OTHER |