Healthcare Provider Details

I. General information

NPI: 1497791487
Provider Name (Legal Business Name): SHAHRIAR MABOURAKH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 CREEKSIDE DR SUITE 110
FOLSOM CA
95630-3492
US

IV. Provider business mailing address

1561 CREEKSIDE DR SUITE 110
FOLSOM CA
95630-3492
US

V. Phone/Fax

Practice location:
  • Phone: 916-984-1600
  • Fax: 916-984-1616
Mailing address:
  • Phone: 916-984-1600
  • Fax: 916-984-1616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG61666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: