Healthcare Provider Details

I. General information

NPI: 1609061191
Provider Name (Legal Business Name): LEO MENG-TAH SHUM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2007
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 E WALNUT ST SUITE 120
PASADENA CA
91106-1451
US

IV. Provider business mailing address

959 E WALNUT ST SUITE 120
PASADENA CA
91106-1451
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-1831
  • Fax: 626-795-2716
Mailing address:
  • Phone: 626-795-1831
  • Fax: 626-795-2716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT188668
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA121518
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA121518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: