Basic Information
| Provider Information | |||||||||
| NPI: | 1023033107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIRAZI | ||||||||
| FirstName: | KEYVAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16952 VENTURA BLVD. | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187893964 | ||||||||
| FaxNumber: | 8187893967 | ||||||||
| Practice Location | |||||||||
| Address1: | 16952 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913164197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187893964 | ||||||||
| FaxNumber: | 8187893967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A78184 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A781840 | 05 | CA | MEDICAID |