Healthcare Provider Details

I. General information

NPI: 1275646952
Provider Name (Legal Business Name): SHAFEEQ S SHAMSID-DEEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5970 S CENTRAL AVE
LOS ANGELES CA
90001
US

IV. Provider business mailing address

1000 SAN GABRIEL BLVD STE 200
ROSEMEAD CA
91770-4394
US

V. Phone/Fax

Practice location:
  • Phone: 323-234-3280
  • Fax: 323-234-3493
Mailing address:
  • Phone: 877-358-5841
  • Fax: 323-248-7044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG36419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: