Provider Demographics
NPI:1558367649
Name:SHIRAZ MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SHIRAZ MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEYVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRAZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-789-3964
Mailing Address - Street 1:16952 VENTURA BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4124
Mailing Address - Country:US
Mailing Address - Phone:818-789-3964
Mailing Address - Fax:818-789-3967
Practice Address - Street 1:16952 VENTURA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4124
Practice Address - Country:US
Practice Address - Phone:818-789-3964
Practice Address - Fax:818-789-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78184207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A781840Medicaid
W16548Medicare ID - Type Unspecified
CA00A781840Medicaid
CA00A781840Medicaid