Provider Demographics
NPI:1699705590
Name:SHAULOV, VITALIY (MD)
Entity type:Individual
Prefix:MR
First Name:VITALIY
Middle Name:
Last Name:SHAULOV
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 1:28895 EL APAJO
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7616
Mailing Address - Country:US
Mailing Address - Phone:949-309-7903
Mailing Address - Fax:949-716-5243
Practice Address - Street 1:25411 CABOT RD
Practice Address - Street 2:SUITE 116
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5520
Practice Address - Country:US
Practice Address - Phone:949-309-7903
Practice Address - Fax:949-716-5243
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA775922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA64M841Medicare PIN
CAG87276Medicare UPIN