Healthcare Provider Details

I. General information

NPI: 1013570563
Provider Name (Legal Business Name): VIVEK DILIPKUMAR SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 560W
SANTA MONICA CA
90404-2182
US

IV. Provider business mailing address

14445 OLIVE VIEW DR # 2B182
SYLMAR CA
91342-1438
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-5654
  • Fax: 310-453-6885
Mailing address:
  • Phone: 747-210-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberA177519
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberA177519
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: