Healthcare Provider Details

I. General information

NPI: 1619194206
Provider Name (Legal Business Name): FARROKH SHADAB MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11180 WARNER AVE SUITE 169
FOUNTAIN VALLEY CA
92708-7501
US

IV. Provider business mailing address

11180 WARNER AVE SUITE 169
FOUNTAIN VALLEY CA
92708-7501
US

V. Phone/Fax

Practice location:
  • Phone: 714-549-1200
  • Fax: 714-549-3238
Mailing address:
  • Phone: 714-549-1200
  • Fax: 714-549-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA337290
License Number StateCA

VIII. Authorized Official

Name: FARROKH SHADAB
Title or Position: PRESIDENT
Credential: MD
Phone: 714-549-1200