Healthcare Provider Details

I. General information

NPI: 1457582934
Provider Name (Legal Business Name): SHAHROUZ DANIEL GANJIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DANIEL GANJIAN MD

II. Dates (important events)

Enumeration Date: 08/02/2009
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 WILSHIRE BLVD STE 100
SANTA MONICA CA
90403-5627
US

IV. Provider business mailing address

1821 WILSHIRE BLVD STE 100
SANTA MONICA CA
90403-5627
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-4403
  • Fax:
Mailing address:
  • Phone: 310-829-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License NumberA113978
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA113978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: