Provider Demographics
NPI:1083746069
Name:GHANEM, SHAHRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:GHANEM
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 1:14350 WHITTIER BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-2147
Mailing Address - Country:US
Mailing Address - Phone:562-698-7070
Mailing Address - Fax:562-698-3588
Practice Address - Street 1:14350 WHITTIER BLVD STE 230
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-2147
Practice Address - Country:US
Practice Address - Phone:562-698-7070
Practice Address - Fax:562-698-3588
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38917207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A38917Medicaid
CAA38917Medicare ID - Type Unspecified
CA00A38917Medicaid