Healthcare Provider Details

I. General information

NPI: 1790774156
Provider Name (Legal Business Name): JERRY JEH SHIH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

FILE 57326
LOS ANGELES CA
90074-7326
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax: 888-539-8781
Mailing address:
  • Phone: 858-249-6748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberG66909
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME93761
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG66909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: