Healthcare Provider Details

I. General information

NPI: 1104269729
Provider Name (Legal Business Name): SHADFAR BAHRI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA SUITE B114
LOS ANGELES CA
90095-5201
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-9513
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberA140110
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberA140110
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberA140110
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207UN0903X
TaxonomyIn Vivo & In Vitro Nuclear Medicine Physician
License NumberA140110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: