MEDICARE: LA PUENTE VALLEY MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1639270093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA PUENTE VALLEY MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	18335 VALLEY BLVD
Second Line	:
City	:	LA PUENTE
State	:	CA
Zip	:	91744-5968
Country	:	US
Telephone Number	:	626-810-3330
Fax Number	:	626-964-0440

Provider Business Practice Location Address
First Line	:	18335 VALLEY BLVD
Second Line	:
City	:	LA PUENTE
State	:	CA
Zip	:	91744-5968
Country	:	US
Telephone Number	:	626-810-3330
Fax Number	:	626-964-0440

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HIREN C SHAH
Credential	:	M.D.
Telephone Number	:	626-810-3330

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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