Provider Demographics
NPI:1164082855
Name:SHAHROOZ, SANAM TIFFANY (MD)
Entity Type:Individual
Prefix:
First Name:SANAM
Middle Name:TIFFANY
Last Name:SHAHROOZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CENTURY PARK E STE 911
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2012
Mailing Address - Country:US
Mailing Address - Phone:310-229-1220
Mailing Address - Fax:310-229-1222
Practice Address - Street 1:2080 CENTURY PARK E STE 911
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2012
Practice Address - Country:US
Practice Address - Phone:310-229-1220
Practice Address - Fax:310-229-1222
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA185754207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XMedicaid