Provider Demographics
NPI:1104997311
Name:SHADI MEDICAL CORPORATION
Entity type:Organization
Organization Name:SHADI MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-938-9999
Mailing Address - Street 1:PO BOX 49879
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-0879
Mailing Address - Country:US
Mailing Address - Phone:323-938-9999
Mailing Address - Fax:323-456-0880
Practice Address - Street 1:8815 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-3301
Practice Address - Country:US
Practice Address - Phone:323-938-9999
Practice Address - Fax:323-456-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78965207RS0012X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104997311Medicaid
CAW16409Medicare ID - Type Unspecified
CA00A789650Medicaid