Healthcare Provider Details

I. General information

NPI: 1467316091
Provider Name (Legal Business Name): DR BAHAREH FAZILAT MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 VAN NUYS BLVD STE 302
SHERMAN OAKS CA
91403-1743
US

IV. Provider business mailing address

4940 VAN NUYS BLVD STE 302
SHERMAN OAKS CA
91403-1743
US

V. Phone/Fax

Practice location:
  • Phone: 310-507-7748
  • Fax: 310-598-7997
Mailing address:
  • Phone: 310-507-7748
  • Fax: 310-598-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: BAHAREH FAZILAT
Title or Position: PRESIDENT
Credential: MD
Phone: 310-507-7748