Provider Demographics
NPI:1457420903
Name:SHAHANE, RAVINDRANATH VISHNU (MD)
Entity type:Individual
Prefix:
First Name:RAVINDRANATH
Middle Name:VISHNU
Last Name:SHAHANE
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 1:1734 N RIVERSIDE AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8058
Mailing Address - Country:US
Mailing Address - Phone:909-875-3595
Mailing Address - Fax:909-875-1029
Practice Address - Street 1:1734 N RIVERSIDE AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8058
Practice Address - Country:US
Practice Address - Phone:909-875-3595
Practice Address - Fax:909-875-1029
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI22950Medicare UPIN