Healthcare Provider Details

I. General information

NPI: 1538346911
Provider Name (Legal Business Name): MICHAEL SHANE HAMMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9339 GENESEE AVE STE 350
SAN DIEGO CA
92121-2150
US

IV. Provider business mailing address

12700 PARK CENTRAL DR STE 1210
DALLAS TX
75251-1522
US

V. Phone/Fax

Practice location:
  • Phone: 858-454-4300
  • Fax: 858-454-5088
Mailing address:
  • Phone: 702-360-2763
  • Fax: 949-783-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA97551
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA97551
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA97551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: