Healthcare Provider Details

I. General information

NPI: 1437282936
Provider Name (Legal Business Name): BABAK ROBERT BAMSHAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 3RD ST NO. 765W
LOS ANGELES CA
90048-6101
US

IV. Provider business mailing address

8635 W 3RD ST NO. 765W
LOS ANGELES CA
90048-6101
US

V. Phone/Fax

Practice location:
  • Phone: 310-854-0777
  • Fax: 310-289-5198
Mailing address:
  • Phone: 310-854-0777
  • Fax: 310-289-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberG81239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: