Healthcare Provider Details

I. General information

NPI: 1053669390
Provider Name (Legal Business Name): BRENDA SHEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N PROSPECT AVE SUITE 103
REDONDO BEACH CA
90277-3041
US

IV. Provider business mailing address

520 N PROSPECT AVE SUITE 103
REDONDO BEACH CA
90277-3041
US

V. Phone/Fax

Practice location:
  • Phone: 310-376-8816
  • Fax:
Mailing address:
  • Phone: 310-376-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA122399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: