Provider Demographics
NPI:1871545434
Name:SHAH, SAMIR ASHOK (MD)
Entity type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:ASHOK
Last Name:SHAH
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 1:18582 MAIN ST
Mailing Address - Street 2:ATTN: TRAILL MCCABE
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1701
Mailing Address - Country:US
Mailing Address - Phone:714-965-9696
Mailing Address - Fax:714-965-9797
Practice Address - Street 1:18582 MAIN ST
Practice Address - Street 2:ATTN: TRAILL MCCABE
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1701
Practice Address - Country:US
Practice Address - Phone:714-965-9696
Practice Address - Fax:714-965-9797
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85961207W00000X
MI4301089354207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI54308Medicare UPIN