Provider Demographics
NPI:1912975350
Name:SHABANZADEH, PAYAM (MD)
Entity Type:Individual
Prefix:
First Name:PAYAM
Middle Name:
Last Name:SHABANZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PAYAM
Other - Middle Name:
Other - Last Name:SHABANZADEH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1025 W OLYMPIC BLVD
Mailing Address - Street 2:(HEALTHCARE PARTNERS)
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015
Mailing Address - Country:US
Mailing Address - Phone:213-623-2225
Mailing Address - Fax:231-861-5863
Practice Address - Street 1:1025 W OLYMPIC BLVD
Practice Address - Street 2:(HEALTHCARE PARTNERS)
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015
Practice Address - Country:US
Practice Address - Phone:213-623-2225
Practice Address - Fax:231-861-5863
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93221207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI51436Medicare UPIN