Provider Demographics
NPI:1780402859
Name:ROOSTAIE, SHADEH
Entity type:Individual
Prefix:
First Name:SHADEH
Middle Name:
Last Name:ROOSTAIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22629 DE KALB DR
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-4803
Mailing Address - Country:US
Mailing Address - Phone:818-297-2351
Mailing Address - Fax:
Practice Address - Street 1:333 SKYWAY DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-8552
Practice Address - Country:US
Practice Address - Phone:805-383-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program