Healthcare Provider Details

I. General information

NPI: 1619507985
Provider Name (Legal Business Name): SAGAR SHAH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2281 CLEVELAND AVE
SANTA ROSA CA
95403-2905
US

IV. Provider business mailing address

4394 RUSTICA CIR
FREMONT CA
94536-7908
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-3337
  • Fax:
Mailing address:
  • Phone: 510-314-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE6265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: