Healthcare Provider Details

I. General information

NPI: 1891138608
Provider Name (Legal Business Name): TONY SHAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 SEPULVEDA BLVD STE 690
SHERMAN OAKS CA
91411-2522
US

IV. Provider business mailing address

5805 SEPULVEDA BLVD STE 690
SHERMAN OAKS CA
91411-2522
US

V. Phone/Fax

Practice location:
  • Phone: 818-900-6480
  • Fax:
Mailing address:
  • Phone: 818-900-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA183684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: