Basic Information
Provider Information | |||||||||
NPI: | 1134395320 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHARIATI | ||||||||
FirstName: | JAMSHID | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4267 MARINA CITY DR | ||||||||
Address2: | UNIT 114 | ||||||||
City: | MARINA DEL REY | ||||||||
State: | CA | ||||||||
PostalCode: | 902925810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108469777 | ||||||||
FaxNumber: | 3108469776 | ||||||||
Practice Location | |||||||||
Address1: | 1117 W MANCHESTER BLVD | ||||||||
Address2: | SUITE K | ||||||||
City: | INGLEWOOD | ||||||||
State: | CA | ||||||||
PostalCode: | 903011500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3102153555 | ||||||||
FaxNumber: | 3102153587 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2008 | ||||||||
LastUpdateDate: | 04/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A105315 | CA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 9042139 | 05 | CA |   | MEDICAID |