Provider Demographics
NPI:1437282936
Name:BAMSHAD, BABAK ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BABAK
Middle Name:ROBERT
Last Name:BAMSHAD
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 1:8635 W 3RD ST
Mailing Address - Street 2:NO. 765W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-854-0777
Mailing Address - Fax:310-289-5198
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:NO. 765W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-854-0777
Practice Address - Fax:310-289-5198
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG812392088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G812391Medicaid
CA00G812391Medicaid
CAG81239Medicare PIN