Healthcare Provider Details

I. General information

NPI: 1942709738
Provider Name (Legal Business Name): AZADEH SHIRAZI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 GIRARD AVE STE 202
LA JOLLA CA
92037-5151
US

IV. Provider business mailing address

7301 GIRARD AVE STE 202
LA JOLLA CA
92037-5151
US

V. Phone/Fax

Practice location:
  • Phone: 858-456-3992
  • Fax: 858-456-4010
Mailing address:
  • Phone: 858-456-3992
  • Fax: 858-456-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: AZADEH SHIRAZI
Title or Position: PHYSICIAN/PRESIDENT
Credential: MD
Phone: 619-309-9831