Healthcare Provider Details

I. General information

NPI: 1053546416
Provider Name (Legal Business Name): SHADI RASHTAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

68 CAVALIER BLVD
FLORENCE KY
41042-1645
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone: 513-475-7630
  • Fax: 859-781-8374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number47222
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number54232
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberV149698
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35123652
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA149698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: