Provider Demographics
NPI:1912079542
Name:LALEZARZADEH, SHIVA (DO)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:
Last Name:LALEZARZADEH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:11600 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5781
Mailing Address - Country:US
Mailing Address - Phone:847-770-6083
Mailing Address - Fax:888-246-1403
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:847-770-6083
Practice Address - Fax:888-246-1403
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A8026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH34515Medicare UPIN