Provider Demographics
NPI:1477675890
Name:SHAFA, BOB BABAK (MD)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:BABAK
Last Name:SHAFA
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-825-5111
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83576207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A835760Medicaid
CAWA83576AMedicare PIN