Provider Demographics
NPI:1497861439
Name:JAVAHERI, SHAHRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:JAVAHERI
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:PO BOX 12512
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5065
Mailing Address - Country:US
Mailing Address - Phone:949-389-0660
Mailing Address - Fax:949-389-0668
Practice Address - Street 1:26691 PLAZA STE 150
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6329
Practice Address - Country:US
Practice Address - Phone:949-389-0660
Practice Address - Fax:949-389-0668
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-114422207RG0100X
CAA064239207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A642390Medicaid
CAW17240Medicare ID - Type Unspecified
CAG92938Medicare UPIN