Healthcare Provider Details

I. General information

NPI: 1407078215
Provider Name (Legal Business Name): NISSAR SHAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HILLMONT AVE STE 401
VENTURA CA
93003-1651
US

IV. Provider business mailing address

3265 S. SEPULVEDA BLVD. #208
LOS ANGELES CA
90034
US

V. Phone/Fax

Practice location:
  • Phone: 805-648-9830
  • Fax:
Mailing address:
  • Phone: 310-390-9317
  • Fax: 310-423-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA84201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: