Healthcare Provider Details

I. General information

NPI: 1154197911
Provider Name (Legal Business Name): SHIDBAN DIALYSIS ACCESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S GRAND AVE STE 100
LOS ANGELES CA
90015-3071
US

IV. Provider business mailing address

1100 WILSHIRE BLVD APT 3101
LOS ANGELES CA
90017-1953
US

V. Phone/Fax

Practice location:
  • Phone: 213-797-6044
  • Fax: 213-481-7023
Mailing address:
  • Phone: 213-797-6044
  • Fax: 213-481-7023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HAMID SHIDBAN
Title or Position: OWNER
Credential: MD
Phone: 213-797-6044