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General NPI Number Information
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NPI Number | 1184608002
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Entity Type | Individual
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Provider Name | SHARO RAISSI M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/05/2005
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Last Update Date | 05/17/2012
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Provider Practice Location Address
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Address Line | 6310 SAN VICENTE BLVD STE 220
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City | LOS ANGELES
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State | CA
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Zip | 90048-5426
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Country | US
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Telephone | 310-291-2166
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Fax | 310-274-0595
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Provider Business Mailing Address
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Address Line | 16750 VIA PACIFICA
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City | PACIFIC PALISADES
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State | CA
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Zip | 90272-1949
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Country | US
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Telephone | 310-291-2166
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Fax | 310-274-0595
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A44836
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License Number State | CA
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