Healthcare Provider Details

I. General information

NPI: 1760578033
Provider Name (Legal Business Name): SHAISTA I SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 THORNTON AVE
NEWARK CA
94560-3747
US

IV. Provider business mailing address

2333 MOWRY AVE SUITE 300
FREMONT CA
94538
US

V. Phone/Fax

Practice location:
  • Phone: 510-791-1798
  • Fax: 510-791-1347
Mailing address:
  • Phone: 510-796-0222
  • Fax: 510-796-7760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA94712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: