Provider Demographics
NPI:1760579379
Name:SHAHLA ABEDI M D A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHAHLA ABEDI M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-831-4144
Mailing Address - Street 1:15 MAREBLU
Mailing Address - Street 2:SUITE 260
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656
Mailing Address - Country:US
Mailing Address - Phone:949-831-4144
Mailing Address - Fax:949-831-6145
Practice Address - Street 1:15 MAREBLU
Practice Address - Street 2:SUITE 260
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656
Practice Address - Country:US
Practice Address - Phone:949-831-4144
Practice Address - Fax:949-831-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30819207W00000X
CAA79258207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A308190Medicaid
CA00A308190Medicaid
CAA30819Medicare ID - Type Unspecified
B62686Medicare UPIN