Provider Demographics
NPI:1780615724
Name:SHADI, PAYAM (MD)
Entity type:Individual
Prefix:
First Name:PAYAM
Middle Name:
Last Name:SHADI
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:PO BOX 49879
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-0879
Mailing Address - Country:US
Mailing Address - Phone:323-938-9999
Mailing Address - Fax:323-456-0880
Practice Address - Street 1:8815 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-3301
Practice Address - Country:US
Practice Address - Phone:323-938-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78965207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780615724OtherMEDICARE
CA1780615724Medicaid
CAH75811Medicare UPIN