=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619276573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAFAGH MONAZZAM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2011
-----------------------------------------------------
Last Update Date | 01/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4067 TWEEDY BLVD
-----------------------------------------------------
City | SOUTH GATE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90280-6146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-569-1126
-----------------------------------------------------
Fax | 877-403-7113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16215 WAYFARER LN
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92649-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-595-2250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | A120465
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------