Healthcare Provider Details

I. General information

NPI: 1770110009
Provider Name (Legal Business Name): SHAYAN ZOGHI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N FRESNO ST
FRESNO CA
93701-2302
US

IV. Provider business mailing address

26 FECAMP
NEWPORT COAST CA
92657-1047
US

V. Phone/Fax

Practice location:
  • Phone: 559-499-6450
  • Fax:
Mailing address:
  • Phone: 559-999-0901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number02007017A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: