Provider Demographics
NPI:1720114432
Name:FARDIN, SHALA RAHBAR (MD)
Entity Type:Individual
Prefix:
First Name:SHALA
Middle Name:RAHBAR
Last Name:FARDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHALA
Other - Middle Name:
Other - Last Name:RAHBAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2330 MARINSHIP WAY STE 370
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2853
Mailing Address - Country:US
Mailing Address - Phone:415-887-9758
Mailing Address - Fax:415-887-9763
Practice Address - Street 1:2330 MARINSHIP WAY STE 370
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-2853
Practice Address - Country:US
Practice Address - Phone:415-887-9758
Practice Address - Fax:415-887-9763
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAP-230971207N00000X
CAA98841207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology