=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942709738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZADEH SHIRAZI MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2018
-----------------------------------------------------
Last Update Date | 02/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7301 GIRARD AVE STE 202
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-5151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-456-3992
-----------------------------------------------------
Fax | 858-456-4010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7301 GIRARD AVE STE 202
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-5151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-456-3992
-----------------------------------------------------
Fax | 858-456-4010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/PRESIDENT
-----------------------------------------------------
Name | AZADEH SHIRAZI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 619-309-9831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------