Provider Demographics
NPI:1780929265
Name:SHARO S RAISSI MD PC
Entity type:Organization
Organization Name:SHARO S RAISSI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARO
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAISSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-291-2166
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:714-829-3011
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:800-756-8714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44386174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty