Healthcare Provider Details

I. General information

NPI: 1255356572
Provider Name (Legal Business Name): SHAHNA G ROGOSIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39650 LIBERTY ST STE 300
FREMONT CA
94538-2227
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-498-2890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC52070
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: