Healthcare Provider Details

I. General information

NPI: 1023464336
Provider Name (Legal Business Name): JAY SHAH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 GRAND AVE STE 125
CHINO HILLS CA
91709-6802
US

IV. Provider business mailing address

2140 GRAND AVE STE 125
CHINO HILLS CA
91709-6802
US

V. Phone/Fax

Practice location:
  • Phone: 909-630-7875
  • Fax: 909-469-2107
Mailing address:
  • Phone: 909-630-7875
  • Fax: 909-469-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A16182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: