Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 35123652 | OH |
N | 207N00000X | Dermatologist | 47222 | KY |
N | 207N00000X | Dermatologist | 54232 | MN |
Y | 207N00000X | Dermatologist | A149698 | CA |
N | 207N00000X | Dermatologist | V149698 | CA |
NPI | 1053546416 |
---|---|
Provider Name | Shadi Rashtak |
First Address | Florence, KY 41042-1645 |
Second Address | Vallejo, CA 94589-2441 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2009 |
Last Update Date | 02/02/2022 |