Healthcare Provider Details

I. General information

NPI: 1144754920
Provider Name (Legal Business Name): SHAWN FREDERICK JOSEPH WHELAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6633 TELEPHONE RD STE 150
VENTURA CA
93003-0713
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 805-642-8252
  • Fax:
Mailing address:
  • Phone: 310-301-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A17039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: