Healthcare Provider Details

I. General information

NPI: 1639894637
Provider Name (Legal Business Name): USMAN S. SHAH, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOAG DR. BLDG 39, 1ST FLOOR
NEWPORT BEACH CA
92663-9266
US

IV. Provider business mailing address

PO BOX 5434
ORANGE CA
92863-5434
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-1801
  • Fax:
Mailing address:
  • Phone: 442-600-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: REBECA LAGUNA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 442-600-5128