Provider Demographics
NPI:1023033107
Name:SHIRAZI, KEYVAN (MD)
Entity Type:Individual
Prefix:
First Name:KEYVAN
Middle Name:
Last Name:SHIRAZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16952 VENTURA BLVD.
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-789-3964
Mailing Address - Fax:818-789-3967
Practice Address - Street 1:16952 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4197
Practice Address - Country:US
Practice Address - Phone:818-789-3964
Practice Address - Fax:818-789-3967
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78184207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A781840Medicaid
CAW16548Medicare ID - Type UnspecifiedMEDICARE GROUP
CAH69565Medicare UPIN
CA00A781840Medicaid