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General NPI Number Information
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NPI Number | 1932211067
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Entity Type | Individual
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Provider Name | SHAHLA MODARRESI MOTAMEDI MD
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Gender | Female
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 11301 WILSHIRE BLVD WEST LA V.A. HOSPITAL.,IMAGING DEPT.,BLDG 500,ROOM 0608
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City | LOS ANGELES
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State | CA
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Zip | 90073-1003
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Country | US
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Telephone | 310-268-3591
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Fax | 310-575-6665
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Provider Business Mailing Address
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Address Line | 326 GEORGINA AVE
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City | SANTA MONICA
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State | CA
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Zip | 90402-1618
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Country | US
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Telephone | 310-458-0050
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Fax | 310-575-6665
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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 | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | A41382
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License Number State | CA
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