Provider Demographics
NPI:1891343521
Name:FARHADI, SHADI (PT)
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:FARHADI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CALLE CAREYES
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673
Mailing Address - Country:US
Mailing Address - Phone:949-606-6818
Mailing Address - Fax:
Practice Address - Street 1:18102 SKY PARK CIR STE D
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6531
Practice Address - Country:US
Practice Address - Phone:949-333-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT295108208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation