Healthcare Provider Details

I. General information

NPI: 1649358599
Provider Name (Legal Business Name): SHAHIN FAZILAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 SOUTH DR STE 25
MOUNTAIN VIEW CA
94040-4209
US

IV. Provider business mailing address

515 SOUTH DR STE 25
MOUNTAIN VIEW CA
94040-4209
US

V. Phone/Fax

Practice location:
  • Phone: 650-964-2200
  • Fax: 650-964-2205
Mailing address:
  • Phone: 650-964-2200
  • Fax: 650-964-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA90907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: