Provider Demographics
NPI:1215927439
Name:SHALOM, FRED MELEK (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:MELEK
Last Name:SHALOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FEREYDOON
Other - Middle Name:MELEK
Other - Last Name:SHALOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3010 W ORANGE AVE
Mailing Address - Street 2:SUITE 506
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3169
Mailing Address - Country:US
Mailing Address - Phone:714-220-0263
Mailing Address - Fax:714-952-2968
Practice Address - Street 1:3010 W ORANGE AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3169
Practice Address - Country:US
Practice Address - Phone:714-220-0263
Practice Address - Fax:714-952-2968
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33545207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A335450Medicaid
CAW10369Medicare ID - Type Unspecified
CA00A335450Medicaid