Provider Demographics
NPI:1891845400
Name:SHAFA, MARK MAHBOD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MAHBOD
Last Name:SHAFA
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:PO BOX 8500, LOCKBOX 7642
Mailing Address - Street 2:SHRINERS HOSPITALS FOR CHILDREN LOS ANGELES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:3160 GENEVA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1117
Practice Address - Country:US
Practice Address - Phone:213-368-3338
Practice Address - Fax:213-368-3314
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61060207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology