Healthcare Provider Details

I. General information

NPI: 1063414977
Provider Name (Legal Business Name): RAZEQ ABDUL SHETAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 12/22/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 COFFEE RD SUITE B-1
MODESTO CA
95355-2413
US

IV. Provider business mailing address

288 W SANTOS AVE
RIPON CA
95366-9337
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1200
  • Fax: 209-578-3757
Mailing address:
  • Phone: 209-599-6018
  • Fax: 209-599-6018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA55408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: