Healthcare Provider Details

I. General information

NPI: 1619276573
Provider Name (Legal Business Name): SHAFAGH MONAZZAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SHAN MONAZZAM MD

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4067 TWEEDY BLVD
SOUTH GATE CA
90280-6146
US

IV. Provider business mailing address

16215 WAYFARER LN
HUNTINGTON BEACH CA
92649-2149
US

V. Phone/Fax

Practice location:
  • Phone: 323-569-1126
  • Fax: 877-403-7113
Mailing address:
  • Phone: 714-595-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA120465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: