Provider Demographics
NPI:1174625933
Name:SHAILAM, SUNITA (MD)
Entity type:Individual
Prefix:
First Name:SUNITA
Middle Name:
Last Name:SHAILAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 C ST STE 216
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5121
Mailing Address - Country:US
Mailing Address - Phone:619-239-4979
Mailing Address - Fax:619-239-5960
Practice Address - Street 1:427 C ST STE 216
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5121
Practice Address - Country:US
Practice Address - Phone:619-239-4979
Practice Address - Fax:619-239-5960
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G97082Medicare UPIN
WA68876BMedicare ID - Type UnspecifiedMEDICARE PROVIDER #