Provider Demographics
NPI:1063421865
Name:SHAMS, FARIBORZ (DO)
Entity type:Individual
Prefix:
First Name:FARIBORZ
Middle Name:
Last Name:SHAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S BEACH BLVD
Mailing Address - Street 2:STE F
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1812
Mailing Address - Country:US
Mailing Address - Phone:714-995-7503
Mailing Address - Fax:
Practice Address - Street 1:515 S BEACH BLVD
Practice Address - Street 2:STE F
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1812
Practice Address - Country:US
Practice Address - Phone:714-995-7503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F96669Medicare UPIN