Healthcare Provider Details

I. General information

NPI: 1720114432
Provider Name (Legal Business Name): SHALA RAHBAR FARDIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHALA RAHBAR MD

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 MARINSHIP WAY STE 370
SAUSALITO CA
94965-2853
US

IV. Provider business mailing address

2330 MARINSHIP WAY STE 370
SAUSALITO CA
94965-2853
US

V. Phone/Fax

Practice location:
  • Phone: 415-887-9758
  • Fax: 415-887-9763
Mailing address:
  • Phone: 415-887-9758
  • Fax: 415-887-9763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberP-230971
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA98841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: