Provider Demographics
NPI:1104817527
Name:SHAH, SUSHMA V (MD)
Entity type:Individual
Prefix:
First Name:SUSHMA
Middle Name:V
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20103 LAKE CHABOT RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5305
Mailing Address - Country:US
Mailing Address - Phone:510-889-5092
Mailing Address - Fax:510-537-0666
Practice Address - Street 1:4301 N STAR WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9262
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-524-4240
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66980207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A669800Medicaid
CA00A669800OtherBLUE SHIELD
CA00A669801Medicare ID - Type Unspecified
CA00A669800Medicaid