Provider Demographics
NPI:1851325716
Name:BEHROOZAN, DANIEL SHAHROOZ (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SHAHROOZ
Last Name:BEHROOZAN
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 1:2221 LINCOLN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1320
Mailing Address - Country:US
Mailing Address - Phone:310-392-1111
Mailing Address - Fax:310-392-1101
Practice Address - Street 1:2221 LINCOLN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1320
Practice Address - Country:US
Practice Address - Phone:310-392-1111
Practice Address - Fax:310-392-1101
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76756207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A767560OtherMEDI-CAL PPIN
CAWA76756DOtherMEDICARE PPIN
CAI13153Medicare UPIN
CA00A767560OtherMEDI-CAL PPIN
CAWA76756CMedicare ID - Type UnspecifiedPPIN