Healthcare Provider Details

I. General information

NPI: 1053317537
Provider Name (Legal Business Name): SHANTHARAM PAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E AIRPORT DR STE 130
SAN BERNARDINO CA
92408-3428
US

IV. Provider business mailing address

202 E AIRPORT DR STE 130
SAN BERNARDINO CA
92408-3428
US

V. Phone/Fax

Practice location:
  • Phone: 909-799-7111
  • Fax: 909-498-5154
Mailing address:
  • Phone: 909-799-7111
  • Fax: 909-498-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA442860
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA442860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: