Healthcare Provider Details

I. General information

NPI: 1124036462
Provider Name (Legal Business Name): SHAYA GHAZINOOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOAG DR
NEWPORT BEACH CA
92663-4162
US

IV. Provider business mailing address

20 EXECUTIVE PARK STE 155
IRVINE CA
92614-4733
US

V. Phone/Fax

Practice location:
  • Phone: 949-645-3534
  • Fax:
Mailing address:
  • Phone: 949-263-8620
  • Fax: 800-409-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA76305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: