MEDICARE: DR. SOORAJ M SHAH

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	207RA0002X	Adult Congenital Heart Disease Physician	276483	NY
2	207RC0000X	Cardiovascular Disease Physician	276483	NY
3	207RI0011X	Interventional Cardiology Physician	276483	NY
4	207RC0000X	Cardiovascular Disease Physician	C170604	CA

General Provider Information

NPI Number	:	1902041643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SOORAJ M SHAH

Provider Business Mailing Address
First Line	:	1640 NEWPORT BLVD STE 445
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-7730
Country	:	US
Telephone Number	:	714-241-9070
Fax Number	:	949-889-2260

Provider Business Practice Location Address
First Line	:	1640 NEWPORT BLVD STE 445
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-7730
Country	:	US
Telephone Number	:	714-241-9070
Fax Number	:	949-889-2260

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2008
Last Update Date	:	10/16/2024

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