Healthcare Provider Details

I. General information

NPI: 1376775924
Provider Name (Legal Business Name): ANKIT VIKRAM SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 01/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 W SUNSET BLVD MODULE 4B
LOS ANGELES CA
90027-6082
US

IV. Provider business mailing address

4700 W SUNSET BLVD MODULE 4B
LOS ANGELES CA
90027-6082
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-8813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA107802
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: