Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | A442860 | CA |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | A442860 | CA |
NPI | 1053317537 |
---|---|
Provider Name | Shantharam Pai |
First Address | San Bernardino, CA 92423-0069 |
Second Address | Redlands, CA 92373-5916 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2005 |
Last Update Date | 16/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A442860 | BLUE SHIELD OF CA (01) | CA |
00A442861 | (05) | CA |
080101190 | RAILROAD MEDICARE (01) | GA |
CA131554 | MEDICARE (01) | CA |
E27394 | (02) | CA |