Healthcare Provider Details

I. General information

NPI: 1750811535
Provider Name (Legal Business Name): NADER SHAKIR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17053 FOOTHILL BLVD
FONTANA CA
92335-3574
US

IV. Provider business mailing address

17053 FOOTHILL BLVD
FONTANA CA
92335-3574
US

V. Phone/Fax

Practice location:
  • Phone: 909-347-1300
  • Fax: 909-347-1302
Mailing address:
  • Phone: 909-347-1300
  • Fax: 909-347-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO-05450
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A-19135
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO-05450
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A-19135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: