Healthcare Provider Details

I. General information

NPI: 1366000614
Provider Name (Legal Business Name): SHADI KAZOURRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2019
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

2565 KENDALL ST
LA VERNE CA
91750-3713
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5000
  • Fax:
Mailing address:
  • Phone: 909-568-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2023-1390
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA183473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: