Provider Demographics
NPI:1942534987
Name:SHABAN AZAR FARR, MD
Entity Type:Organization
Organization Name:SHABAN AZAR FARR, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHABAN
Authorized Official - Middle Name:AZAR
Authorized Official - Last Name:FARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-360-2800
Mailing Address - Street 1:18541 SHERMAN WAY
Mailing Address - Street 2:#101
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335
Mailing Address - Country:US
Mailing Address - Phone:818-360-2800
Mailing Address - Fax:818-363-2100
Practice Address - Street 1:18541 SHERMAN WAY
Practice Address - Street 2:#101
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:818-996-9479
Practice Address - Fax:818-363-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32840208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB50211Medicare UPIN
CAA32840Medicare PIN