Healthcare Provider Details

I. General information

NPI: 1184783086
Provider Name (Legal Business Name): SHIVA G GOLSHANI-HEBRONI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 04/19/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11833 WILMINGTON AVE
LOS ANGELES CA
90059-3015
US

IV. Provider business mailing address

11833 WILMINGTON AVE
LOS ANGELES CA
90059-3015
US

V. Phone/Fax

Practice location:
  • Phone: 310-678-8672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG78243
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberG078243
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG078243
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: