MEDICARE: DR. BAHAREH FAZILAT MD

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	207VG0400X	Gynecology Physician	CA90071	CA
2	207V00000X	Obstetrics & Gynecology Physician	CA90071	CA

General Provider Information

NPI Number	:	1770598534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BAHAREH FAZILAT MD

Provider Business Mailing Address
First Line	:	4940 VAN NUYS BLVD STE 302
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-1743
Country	:	US
Telephone Number	:	310-507-7748
Fax Number	:	310-598-7997

Provider Business Practice Location Address
First Line	:	4940 VAN NUYS BLVD STE 302
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-1743
Country	:	US
Telephone Number	:	310-507-7748
Fax Number	:	310-598-7997

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

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	10/22/2024

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