=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174509772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DWIGHT SHEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 MUIR RD
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-4668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-372-2126
-----------------------------------------------------
Fax | 925-372-2017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 KAINS AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94706-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-527-6082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 45611
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------