Healthcare Provider Details

I. General information

NPI: 1487931440
Provider Name (Legal Business Name): MIAN MOHSIN SHAH AMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N TUSTIN AVE SUITE 109
SANTA ANA CA
92705-3528
US

IV. Provider business mailing address

999 N TUSTIN AVE SUITE 109
SANTA ANA CA
92705-3528
US

V. Phone/Fax

Practice location:
  • Phone: 714-973-1388
  • Fax: 949-284-0604
Mailing address:
  • Phone: 714-973-1388
  • Fax: 949-284-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA066315
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA066315
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberA066315
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA066315
License Number StateCA

VIII. Authorized Official

Name: DR. MIAN MOHSIN SHAH
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 714-973-1388