Healthcare Provider Details

I. General information

NPI: 1508171570
Provider Name (Legal Business Name): SHAHIN FOROUTAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 301
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

PO BOX 1020
STOCKTON CA
95201-3120
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax: 360-514-6063
Mailing address:
  • Phone: 209-468-6000
  • Fax: 209-468-7042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD208986
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD208986
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD208986
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD208986
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA118403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: