Basic Information
| Provider Information | |||||||||
| NPI: | 1629148606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHALTS | ||||||||
| FirstName: | INA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5957 S MOONEY BLVD | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932779394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597374669 | ||||||||
| FaxNumber: | 5597374697 | ||||||||
| Practice Location | |||||||||
| Address1: | 1062 S K ST | ||||||||
| Address2: | |||||||||
| City: | TULARE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932746421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596852614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A56321 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A563210 | 05 | CA | MEDICAID |