Healthcare Provider Details

I. General information

NPI: 1316913866
Provider Name (Legal Business Name): SHANTHA N. URSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD 150 MUIR ROAD
MARTINEZ CA
94553-4668
US

IV. Provider business mailing address

21 SELBORNE DR
PIEDMONT CA
94611-3618
US

V. Phone/Fax

Practice location:
  • Phone: 925-372-2000
  • Fax: 925-370-4031
Mailing address:
  • Phone: 510-482-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA 29848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: