Healthcare Provider Details

I. General information

NPI: 1942246111
Provider Name (Legal Business Name): HAMID SHIDBAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 SAN PABLO ST FL 2
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5908
  • Fax:
Mailing address:
  • Phone: 323-442-5908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberA48781
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA48781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: