Healthcare Provider Details

I. General information

NPI: 1851325716
Provider Name (Legal Business Name): DANIEL SHAHROOZ BEHROOZAN M..D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 LINCOLN BLVD SUITE 100
SANTA MONICA CA
90405-1320
US

IV. Provider business mailing address

2221 LINCOLN BLVD SUITE 100
SANTA MONICA CA
90405-1320
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-1111
  • Fax: 310-392-1101
Mailing address:
  • Phone: 310-392-1111
  • Fax: 310-392-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA76756
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA76756
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA76756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: