Provider Demographics
NPI:1992912950
Name:GENDY-SHAKER, ELIZABETH S (MD)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:S
Last Name:GENDY-SHAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:S
Other - Last Name:GENDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1690 BARTON RD STE 104
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4230
Practice Address - Country:US
Practice Address - Phone:909-795-4747
Practice Address - Fax:909-793-8146
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45113208000000X, 2080P0214X
CAA97366208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ664353Medicaid