Healthcare Provider Details

I. General information

NPI: 1215208673
Provider Name (Legal Business Name): SHIV BHANU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6733 CANYON HILL DR
RIVERSIDE CA
92506-5672
US

IV. Provider business mailing address

6733 CANYON HILL DR
RIVERSIDE CA
92506-5672
US

V. Phone/Fax

Practice location:
  • Phone: 951-780-1506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA133806
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: