Provider Demographics
NPI:1649299280
Name:SAFVATI, SHADAN (MD)
Entity type:Individual
Prefix:
First Name:SHADAN
Middle Name:
Last Name:SAFVATI
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 1:11600 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5781
Mailing Address - Country:US
Mailing Address - Phone:310-312-0101
Mailing Address - Fax:310-312-0102
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 12
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:310-312-0101
Practice Address - Fax:310-312-0102
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist