Healthcare Provider Details

I. General information

NPI: 1962160564
Provider Name (Legal Business Name): SHAHRAM S FARAHVASH MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15732 SUTTON ST
ENCINO CA
91436-3407
US

IV. Provider business mailing address

15732 SUTTON ST
ENCINO CA
91436-3407
US

V. Phone/Fax

Practice location:
  • Phone: 917-349-4943
  • Fax:
Mailing address:
  • Phone: 173-494-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: SHAHRAM SHAWN FARAHVASH
Title or Position: CEO
Credential: MD
Phone: 917-349-4943