Provider Demographics
NPI:1699433011
Name:SHAHRAM BONYADLOU, MD, INC.
Entity type:Organization
Organization Name:SHAHRAM BONYADLOU, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BONYADLOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-528-1183
Mailing Address - Street 1:PO BOX 5227
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-9673
Mailing Address - Country:US
Mailing Address - Phone:310-528-1183
Mailing Address - Fax:
Practice Address - Street 1:522 W CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2635
Practice Address - Country:US
Practice Address - Phone:310-528-1183
Practice Address - Fax:424-781-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology