Healthcare Provider Details

I. General information

NPI: 1205464807
Provider Name (Legal Business Name): OMAR KHALED SHAHIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number05485
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: