Provider Demographics
NPI:1871805432
Name:SHAH, SAMINA (DIETITIAN)
Entity type:Individual
Prefix:
First Name:SAMINA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 ORION RD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1718
Mailing Address - Country:US
Mailing Address - Phone:949-679-1650
Mailing Address - Fax:
Practice Address - Street 1:4540 CAMPUS DR
Practice Address - Street 2:STE#115
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1815
Practice Address - Country:US
Practice Address - Phone:949-874-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA711336133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered