Provider Demographics
NPI:1922068360
Name:MANAVI, SHAHRYAR SHAWN (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRYAR
Middle Name:SHAWN
Last Name:MANAVI
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 1:214 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3556
Mailing Address - Country:US
Mailing Address - Phone:818-241-0970
Mailing Address - Fax:818-638-0024
Practice Address - Street 1:214 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-3556
Practice Address - Country:US
Practice Address - Phone:818-241-0970
Practice Address - Fax:818-638-0024
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67461174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA67461BOtherPALMETTO GBA