Provider Demographics
NPI:1881725901
Name:ARDALAN, SHAHRAM (DC)
Entity type:Individual
Prefix:DR
First Name:SHAHRAM
Middle Name:
Last Name:ARDALAN
Suffix:
Gender:M
Credentials:DC
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 18828
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91416-8828
Mailing Address - Country:US
Mailing Address - Phone:818-995-4488
Mailing Address - Fax:818-995-3140
Practice Address - Street 1:17000 VENTURA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4187
Practice Address - Country:US
Practice Address - Phone:818-995-4488
Practice Address - Fax:818-995-3140
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23493111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU57515Medicare UPIN
CADC23493Medicare ID - Type Unspecified