Provider Demographics
NPI:1477605152
Name:MEEHAN, SHANE M (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:MEEHAN
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:FILE 1440
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-1440
Mailing Address - Country:US
Mailing Address - Phone:858-939-3660
Mailing Address - Fax:
Practice Address - Street 1:9295 FARNHAM ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1254
Practice Address - Country:US
Practice Address - Phone:858-939-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC134989207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093846Medicaid
L56428Medicare ID - Type Unspecified