Healthcare Provider Details

I. General information

NPI: 1962407767
Provider Name (Legal Business Name): SHAHRIYAR TAVAKOLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41750 RANCHO LAS PALMAS DR STE M3
RANCHO MIRAGE CA
92270-5511
US

IV. Provider business mailing address

41750 RANCHO LAS PALMAS DR STE M3
RANCHO MIRAGE CA
92270-5511
US

V. Phone/Fax

Practice location:
  • Phone: 760-895-4292
  • Fax: 760-895-4015
Mailing address:
  • Phone: 760-895-4292
  • Fax: 760-895-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA48572
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA48572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: