Healthcare Provider Details

I. General information

NPI: 1548723091
Provider Name (Legal Business Name): SHAUGHN MITCHELL HEAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 15TH ST STE A
WEST SACRAMENTO CA
95691-3737
US

IV. Provider business mailing address

1860 HOWE AVE STE 440
SACRAMENTO CA
95825-1098
US

V. Phone/Fax

Practice location:
  • Phone: 916-454-2345
  • Fax:
Mailing address:
  • Phone: 916-569-8484
  • 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 Code208000000X
TaxonomyPediatrics Physician
License Number188415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: