Healthcare Provider Details

I. General information

NPI: 1578621074
Provider Name (Legal Business Name): MOHAMMAD SHENASA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N BASCOM AVE SUITE 204
SAN JOSE CA
95128-1811
US

IV. Provider business mailing address

105 N BASCOM AVE SUITE 204
SAN JOSE CA
95128-1811
US

V. Phone/Fax

Practice location:
  • Phone: 408-918-0400
  • Fax: 408-286-2922
Mailing address:
  • Phone: 408-918-0400
  • Fax: 408-286-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA50310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: