Healthcare Provider Details

I. General information

NPI: 1063049922
Provider Name (Legal Business Name): RONGZI SHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 ZONAL AVE STE 4P1
LOS ANGELES CA
90033-1026
US

IV. Provider business mailing address

1200 N STATE ST
LOS ANGELES CA
90089-1001
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-1000
  • Fax:
Mailing address:
  • Phone: 323-409-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA179945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: