Provider Demographics
NPI:1891896841
Name:FARIVAR, SIRUS (MD)
Entity Type:Individual
Prefix:
First Name:SIRUS
Middle Name:
Last Name:FARIVAR
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 1:17822 BEACH BLVD
Mailing Address - Street 2:STE 437
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-7101
Mailing Address - Country:US
Mailing Address - Phone:714-841-7878
Mailing Address - Fax:
Practice Address - Street 1:17822 BEACH BLVD
Practice Address - Street 2:STE 437
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7101
Practice Address - Country:US
Practice Address - Phone:714-841-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36333207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A363330Medicaid
CA00A363330Medicaid