Provider Demographics
NPI:1679648117
Name:MOMTAZI, SHAHAB (MD)
Entity Type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:MOMTAZI
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 4199
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93278
Mailing Address - Country:US
Mailing Address - Phone:559-627-6363
Mailing Address - Fax:559-627-3627
Practice Address - Street 1:202 W WILLOW
Practice Address - Street 2:# 305
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-732-0762
Practice Address - Fax:559-627-5192
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68758207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G687580Medicaid
CA00G687580Medicaid
00G687580Medicare ID - Type Unspecified