Provider Demographics
NPI:1912071556
Name:MIRHASHEMI, SHAHRAM S (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:S
Last Name:MIRHASHEMI
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 1:1535 E COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11273 LAUREL CANYON BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4357
Practice Address - Country:US
Practice Address - Phone:818-853-2220
Practice Address - Fax:818-853-2221
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA96427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13536OtherGROUP MEDICARE #
CAGR0066310Medicaid