Provider Demographics
NPI:1952430324
Name:M SHOKRAEI MD INC
Entity type:Organization
Organization Name:M SHOKRAEI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHOKRAEI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-881-0671
Mailing Address - Street 1:PO BOX 491221
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-9221
Mailing Address - Country:US
Mailing Address - Phone:818-881-0671
Mailing Address - Fax:818-881-7762
Practice Address - Street 1:6670 RESEDA BLVD
Practice Address - Street 2:SUITE # 105
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5327
Practice Address - Country:US
Practice Address - Phone:818-881-0671
Practice Address - Fax:818-881-7762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53012B302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA53012BOtherMEDICAL LIC. NO.
CAF91390Medicare UPIN
CAA53012BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.