Basic Information
| Provider Information | |||||||||
| NPI: | 1568995462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | DINESH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 W AVENUE 26 | ||||||||
| Address2: | APARTMENT 415 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900313091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082427210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232267556 | ||||||||
| FaxNumber: | 3232262657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 159163 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
ID Information
| ID | Type | State | Issuer | Description | SS3232267556 | 05 | CA | MEDICAID | SS3232267556 | 01 | CA | SS3232267556 | OTHER |