Provider Demographics
NPI:1619276573
Name:MONAZZAM, SHAFAGH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAFAGH
Middle Name:
Last Name:MONAZZAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SHAN
Other - Middle Name:
Other - Last Name:MONAZZAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:16215 WAYFARER LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-2149
Mailing Address - Country:US
Mailing Address - Phone:714-595-2250
Mailing Address - Fax:
Practice Address - Street 1:4067 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6146
Practice Address - Country:US
Practice Address - Phone:323-569-1126
Practice Address - Fax:877-403-7113
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120465207XS0114X
IL036.145247207XS0114X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA130223Medicaid