Healthcare Provider Details

I. General information

NPI: 1356856694
Provider Name (Legal Business Name): ALI SHOOSHTARI ALAVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5078 MANOR RIDGE LN
SAN DIEGO CA
92130-2896
US

IV. Provider business mailing address

5078 MANOR RIDGE LN
SAN DIEGO CA
92130-2896
US

V. Phone/Fax

Practice location:
  • Phone: 949-562-4039
  • Fax: 949-239-7799
Mailing address:
  • Phone: 949-562-4039
  • Fax: 949-239-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA163793
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA163793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: