Provider Demographics
NPI:1659833549
Name:FATCH, SHIREE SEGEV (DO)
Entity type:Individual
Prefix:
First Name:SHIREE
Middle Name:SEGEV
Last Name:FATCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LEAD HILL BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3072
Mailing Address - Country:US
Mailing Address - Phone:916-783-0580
Mailing Address - Fax:
Practice Address - Street 1:1650 LEAD HILL BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3072
Practice Address - Country:US
Practice Address - Phone:916-783-0580
Practice Address - Fax:916-783-1824
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2025-08-13
Deactivation Date:2025-06-20
Deactivation Code:
Reactivation Date:2025-08-07
Provider Licenses
StateLicense IDTaxonomies
CA20A20222208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program