Provider Demographics
NPI:1811914864
Name:SHADAB, FARROKH (MD)
Entity type:Individual
Prefix:DR
First Name:FARROKH
Middle Name:
Last Name:SHADAB
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 1:11180 WARNER AVE
Mailing Address - Street 2:SUITE 169
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7501
Mailing Address - Country:US
Mailing Address - Phone:714-549-1200
Mailing Address - Fax:714-549-3238
Practice Address - Street 1:11180 WARNER AVE
Practice Address - Street 2:SUITE 169
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7501
Practice Address - Country:US
Practice Address - Phone:714-549-1200
Practice Address - Fax:714-549-3238
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A37290OtherBLUE CROSS BLUE SHIELD
CA00A337290Medicaid
CA00A337290Medicaid