Healthcare Provider Details

I. General information

NPI: 1568669596
Provider Name (Legal Business Name): SHAHAB MEHDIZADEH MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S LA CIENEGA BLVD 102
BEVERLY HILLS CA
90211-3324
US

IV. Provider business mailing address

240 S LA CIENEGA BLVD 102
BEVERLY HILLS CA
90211-3324
US

V. Phone/Fax

Practice location:
  • Phone: 310-246-4100
  • Fax: 310-285-2029
Mailing address:
  • Phone: 310-246-4100
  • Fax: 310-285-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA76490
License Number StateCA

VIII. Authorized Official

Name: DR. SHAHAB MEHDIZADEH
Title or Position: PRESIDENT
Credential: MD
Phone: 310-246-4100