Healthcare Provider Details

I. General information

NPI: 1699433011
Provider Name (Legal Business Name): SHAHRAM BONYADLOU, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 W CARSON ST
CARSON CA
90745-2635
US

IV. Provider business mailing address

PO BOX 5227
PALOS VERDES ESTATES CA
90274-9673
US

V. Phone/Fax

Practice location:
  • Phone: 310-528-1183
  • Fax: 424-781-8651
Mailing address:
  • Phone: 310-528-1183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAHRAM BONYADLOU
Title or Position: PRESIDENT
Credential: MD
Phone: 310-528-1183