Provider Demographics
NPI:1568886075
Name:YADEGARAN, SHADI
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:YADEGARAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 W ALAMEDA AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4800
Mailing Address - Country:US
Mailing Address - Phone:818-558-7075
Mailing Address - Fax:
Practice Address - Street 1:2601 W ALAMEDA AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4800
Practice Address - Country:US
Practice Address - Phone:310-558-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4946213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery