Healthcare Provider Details

I. General information

NPI: 1104745140
Provider Name (Legal Business Name): SHERVIN HEJAZI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8859 FREMONT AVE UNIT 312
MONTCLAIR CA
91763-3059
US

IV. Provider business mailing address

8859 FREMONT AVE UNIT 312
MONTCLAIR CA
91763-3059
US

V. Phone/Fax

Practice location:
  • Phone: 858-705-5986
  • Fax:
Mailing address:
  • Phone: 858-705-5986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number39020000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: