Provider Demographics
NPI:1104877497
Name:SHAHROKNI, SEYED H (MD)
Entity type:Individual
Prefix:DR
First Name:SEYED
Middle Name:H
Last Name:SHAHROKNI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27758 SANTA MARGARITA PARKWAY
Mailing Address - Street 2:#409
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6709
Mailing Address - Country:US
Mailing Address - Phone:949-364-5716
Mailing Address - Fax:949-364-5777
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA673102085R0202X, 261QR0200X, 261QR0206X, 2085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A673100Medicaid
CAA67310OtherSTATE LICENSE
P00240672OtherRAILROAD MEDICARE
CAWA67310DMedicare PIN
CAA67310OtherSTATE LICENSE