Provider Demographics
NPI:1184608002
Name:RAISSI, SHARO (MD)
Entity type:Individual
Prefix:DR
First Name:SHARO
Middle Name:
Last Name:RAISSI
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 1:16750 VIA PACIFICA
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-1949
Mailing Address - Country:US
Mailing Address - Phone:310-291-2166
Mailing Address - Fax:310-274-0595
Practice Address - Street 1:6310 SAN VICENTE BLVD
Practice Address - Street 2:STE 220
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5426
Practice Address - Country:US
Practice Address - Phone:310-291-2166
Practice Address - Fax:310-274-0595
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44836174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02542Medicare UPIN