Healthcare Provider Details

I. General information

NPI: 1407136187
Provider Name (Legal Business Name): PRAVIN SHAW D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 BAKER ST STE 100
COSTA MESA CA
92626-4105
US

IV. Provider business mailing address

PO BOX 3699
NEWPORT BEACH CA
92659-8699
US

V. Phone/Fax

Practice location:
  • Phone: 714-668-2500
  • Fax: 714-668-2515
Mailing address:
  • Phone: 714-668-2500
  • Fax: 714-668-2515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: