Provider Demographics
NPI:1689619454
Name:SHAUN S DANESHRAD MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SHAUN S DANESHRAD MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DANESHRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-652-5210
Mailing Address - Street 1:PO BOX 2054
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90213-2054
Mailing Address - Country:US
Mailing Address - Phone:310-652-5210
Mailing Address - Fax:
Practice Address - Street 1:8920 WILSHIRE BLVD
Practice Address - Street 2:SUITE 420
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2007
Practice Address - Country:US
Practice Address - Phone:310-652-5210
Practice Address - Fax:310-652-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70241174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF22701Medicare UPIN
CAW19876Medicare PIN