Healthcare Provider Details

I. General information

NPI: 1083826853
Provider Name (Legal Business Name): JASON R SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8000
  • Fax:
Mailing address:
  • Phone: 909-558-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA94088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: