Healthcare Provider Details

I. General information

NPI: 1003922162
Provider Name (Legal Business Name): AVA T SHAMBAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SANTA MONICA BLVD SUITE 600E
SANTA MONICA CA
90404
US

IV. Provider business mailing address

2021 SANTA MONICA BLVD STE 600E
SANTA MONICA CA
90404-2166
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-2282
  • Fax: 310-828-8504
Mailing address:
  • Phone: 310-828-2282
  • Fax: 310-828-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG50969
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG50969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: