Healthcare Provider Details

I. General information

NPI: 1336301258
Provider Name (Legal Business Name): SHOBA RAO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W ARROW HWY STE 104
SAN DIMAS CA
91773-2337
US

IV. Provider business mailing address

801 S CHEVY CHASE DR #20
GLENDALE CA
91205-4431
US

V. Phone/Fax

Practice location:
  • Phone: 909-394-9004
  • Fax:
Mailing address:
  • Phone: 818-637-7980
  • Fax: 818-637-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA116046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: