Provider Demographics
NPI:1154413102
Name:SHABAN, AHMAD (MD)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:SHABAN
Suffix:
Gender:M
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:PO BOX 8223
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-8223
Mailing Address - Country:US
Mailing Address - Phone:949-364-2611
Mailing Address - Fax:949-364-0226
Practice Address - Street 1:26732 CROWN VALLEY PKWY STE 241
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-2611
Practice Address - Fax:949-364-0226
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32547207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA32547AOtherMEDICARE
CAAS9014995OtherDEA
CAAS9014995OtherDEA