Healthcare Provider Details

I. General information

NPI: 1851596381
Provider Name (Legal Business Name): SHAHROUZ S DADFARIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E HARDY ST
INGLEWOOD CA
90301-4011
US

IV. Provider business mailing address

PO BOX 660447
ARCADIA CA
91066-0447
US

V. Phone/Fax

Practice location:
  • Phone: 310-419-8636
  • Fax:
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA95833
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA95833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: