Healthcare Provider Details

I. General information

NPI: 1992912950
Provider Name (Legal Business Name): ELIZABETH S GENDY-SHAKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH S GENDY M.D.

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 BARTON RD STE 104
REDLANDS CA
92373-4230
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-795-4747
  • Fax: 909-793-8146
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number45113
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA97366
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberA97366
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45113
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: