1508177114 NPI number — DR. STEPHEN FARAZ SHAFIZADEH MD PHD DC

Table of content: DR. STEPHEN FARAZ SHAFIZADEH MD PHD DC (NPI 1508177114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508177114 NPI number — DR. STEPHEN FARAZ SHAFIZADEH MD PHD DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAFIZADEH
Provider First Name:
STEPHEN
Provider Middle Name:
FARAZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAFIZADEH
Provider Other First Name:
FARAZ
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508177114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 S BOWMAN RD APT 1723
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72211-4655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-440-0801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N PEPPER AVE STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-1819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-580-1366
Provider Business Practice Location Address Fax Number:
909-580-1363
Provider Enumeration Date:
06/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  125050087 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 192487001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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