Healthcare Provider Details

I. General information

NPI: 1932843216
Provider Name (Legal Business Name): RADHA VIPUL SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2022
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FOOTHILL BLVD
LA CANADA CA
91011-1413
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 818-790-1103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA200579
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: