Healthcare Provider Details

I. General information

NPI: 1598042178
Provider Name (Legal Business Name): SHIVANAND R POLE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 10/11/2025
Certification Date: 10/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 KATELLA AVE STE 321
LOS ALAMITOS CA
90720-3369
US

IV. Provider business mailing address

3801 KATELLA AVE STE 321
LOS ALAMITOS CA
90720-3369
US

V. Phone/Fax

Practice location:
  • Phone: 562-546-7282
  • Fax: 562-546-7284
Mailing address:
  • Phone: 562-546-7282
  • Fax: 562-546-7284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA101547
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberA101547
License Number StateCA

VIII. Authorized Official

Name: DR. SHIVANAND R POLE
Title or Position: PRESIDENT
Credential: MD
Phone: 562-546-7282