Provider Demographics
NPI:1326495235
Name:SHABAN, KOMOLA AZIMOVA (MD)
Entity type:Individual
Prefix:DR
First Name:KOMOLA
Middle Name:AZIMOVA
Last Name:SHABAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KOMOLA
Other - Middle Name:
Other - Last Name:AZIMOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5319 DUPUY CIR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-3165
Mailing Address - Country:US
Mailing Address - Phone:512-650-6550
Mailing Address - Fax:
Practice Address - Street 1:2071 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6101
Practice Address - Country:US
Practice Address - Phone:512-650-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA174548207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine