Healthcare Provider Details

I. General information

NPI: 1306891841
Provider Name (Legal Business Name): FARID F SHAFAIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 SOUTH OAK PARK AVE.
BERWYN IL
60402
US

IV. Provider business mailing address

1770 IOWA AVE STE 280
RIVERSIDE CA
92507-7401
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3152
  • Fax: 708-783-3164
Mailing address:
  • Phone: 951-786-0801
  • Fax: 708-783-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number12090
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number036107562
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC1-0025650
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35-07-4492-S
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101049809
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD57087
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number110062
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-107562
License Number StateIL
# 9
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME134254
License Number StateFL
# 10
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberL6173
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: