1619276573 NPI number — DR. SHAFAGH MONAZZAM MD

Table of content: DR. SHAFAGH MONAZZAM MD (NPI 1619276573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619276573 NPI number — DR. SHAFAGH MONAZZAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONAZZAM
Provider First Name:
SHAFAGH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONAZZAM
Provider Other First Name:
SHAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619276573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16215 WAYFARER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92649-2149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-595-2250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4067 TWEEDY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH GATE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90280-6146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-569-1126
Provider Business Practice Location Address Fax Number:
877-403-7113
Provider Enumeration Date:
03/17/2011

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: 207XS0114X , with the licence number:  A120465 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130223 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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