Healthcare Provider Details

I. General information

NPI: 1265630016
Provider Name (Legal Business Name): IMRAN SHAFI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 12/06/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9985 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

16011 BUTTERFIELD RANCH RD # 228
CHINO HILLS CA
91709-7455
US

V. Phone/Fax

Practice location:
  • Phone: 909-974-4719
  • Fax:
Mailing address:
  • Phone: 909-606-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA 106930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: