=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942534987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHABAN AZAR FARR, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 09/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18541 SHERMAN WAY #101
-----------------------------------------------------
City | RESEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-996-9479
-----------------------------------------------------
Fax | 818-363-2100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18541 SHERMAN WAY #101
-----------------------------------------------------
City | RESEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-360-2800
-----------------------------------------------------
Fax | 818-363-2100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MR. SHABAN AZAR FARR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-360-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A32840
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------