=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033467428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAHAB MAHBOUBIAN, DO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2012
-----------------------------------------------------
Last Update Date | 08/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10640 RIVERSIDE DR
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91602-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-755-6500
-----------------------------------------------------
Fax | 818-755-8904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10640 RIVERSIDE DR
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91602-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-755-6500
-----------------------------------------------------
Fax | 818-755-8904
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHAHAB MAHBOUBIAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 818-209-6528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 20A10721
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------