=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467316091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR BAHAREH FAZILAT MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2025
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4940 VAN NUYS BLVD STE 302
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-507-7748
-----------------------------------------------------
Fax | 310-598-7997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4940 VAN NUYS BLVD STE 302
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-507-7748
-----------------------------------------------------
Fax | 310-598-7997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BAHAREH FAZILAT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-507-7748
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083B0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------