Healthcare Provider Details

I. General information

NPI: 1790715241
Provider Name (Legal Business Name): SHAHAB MEHDIZADEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

240 S LA CIENEGA BLVD SUIT 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:
Title or Position:
Credential:
Phone: