Provider Demographics
NPI:1528246196
Name:AVA T SHAMBAN MD INC
Entity type:Organization
Organization Name:AVA T SHAMBAN MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHAMBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-2282
Mailing Address - Street 1:PO BOX 2248
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92286-2248
Mailing Address - Country:US
Mailing Address - Phone:310-828-2282
Mailing Address - Fax:310-828-8504
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:#600E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-828-2282
Practice Address - Fax:310-828-8504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG50969DMedicare PIN
CAW13960Medicare PIN
CAE57567Medicare UPIN
CAE57567Medicare PIN
CAW13960Medicare UPIN