Healthcare Provider Details

I. General information

NPI: 1790755163
Provider Name (Legal Business Name): SHAHRZAD SOROURBAKHSH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 MURRIETA BLVD
LIVERMORE CA
94550-4113
US

IV. Provider business mailing address

1134 MURRIETA BLVD
LIVERMORE CA
94550-4113
US

V. Phone/Fax

Practice location:
  • Phone: 925-449-7795
  • Fax: 925-449-7953
Mailing address:
  • Phone: 925-449-7795
  • Fax: 925-449-7953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number209894
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA77260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: