MEDICARE: SHIVA G GOLSHANI-HEBRONI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	G078243	CA
2	208000000X	Pediatrics Physician	G78243	CA
3	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician	G078243	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CMS169253	OTHER	CA	CA MEDI-CAL

General Provider Information

NPI Number	:	1184783086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIVA G GOLSHANI-HEBRONI M.D.

Provider Business Mailing Address
First Line	:	11833 WILMINGTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90059-3015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11833 WILMINGTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90059-3015
Country	:	US
Telephone Number	:	310-678-8672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	04/19/2023

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