Provider Demographics
NPI:1568669596
Name:SHAHAB MEHDIZADEH MD INC
Entity Type:Organization
Organization Name:SHAHAB MEHDIZADEH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHDIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-246-4100
Mailing Address - Street 1:240 S LA CIENEGA BLVD
Mailing Address - Street 2:102
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3324
Mailing Address - Country:US
Mailing Address - Phone:310-246-4100
Mailing Address - Fax:310-285-2029
Practice Address - Street 1:240 S LA CIENEGA BLVD
Practice Address - Street 2:102
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3324
Practice Address - Country:US
Practice Address - Phone:310-246-4100
Practice Address - Fax:310-285-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76490207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA76490OtherLICENSE