Provider Demographics
NPI:1851590947
Name:SHADJAREH, MIR J (DC)
Entity Type:Individual
Prefix:DR
First Name:MIR
Middle Name:J
Last Name:SHADJAREH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14252 CULVER DR
Mailing Address - Street 2:A198
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0317
Mailing Address - Country:US
Mailing Address - Phone:714-655-7292
Mailing Address - Fax:
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:145
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3122
Practice Address - Country:US
Practice Address - Phone:949-333-2224
Practice Address - Fax:949-333-2225
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22848111N00000X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NX0800XChiropractic ProvidersChiropractorOrthopedic