Healthcare Provider Details

I. General information

NPI: 1992492375
Provider Name (Legal Business Name): SHANT STEPHANIAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 S SAN MATEO DR
SAN MATEO CA
94401-3857
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-8370
  • Fax:
Mailing address:
  • Phone: 650-652-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA25711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: