Healthcare Provider Details

I. General information

NPI: 1396861951
Provider Name (Legal Business Name): CARL EDWIN SHANGLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE CHOC CHILDREN'S SPECIALISTS
ORANGE CA
92868-4203
US

IV. Provider business mailing address

1201 W LA VETA AVE CHOC CHILDREN'S SPECIALISTS
ORANGE CA
92868-4203
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-3096
  • Fax: 714-509-3096
Mailing address:
  • Phone: 714-509-3096
  • Fax: 714-509-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA104499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: