MEDICARE: SHALA RAHBAR FARDIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	P-230971	MA
2	207N00000X	Dermatology Physician	A98841	CA

General Provider Information

NPI Number	:	1720114432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALA RAHBAR FARDIN MD

Provider Business Mailing Address
First Line	:	2330 MARINSHIP WAY STE 370
Second Line	:
City	:	SAUSALITO
State	:	CA
Zip	:	94965-2853
Country	:	US
Telephone Number	:	415-887-9758
Fax Number	:	415-887-9763

Provider Business Practice Location Address
First Line	:	2330 MARINSHIP WAY STE 370
Second Line	:
City	:	SAUSALITO
State	:	CA
Zip	:	94965-2853
Country	:	US
Telephone Number	:	415-887-9758
Fax Number	:	415-887-9763

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	09/24/2013

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