Provider Demographics
NPI:1992962534
Name:BANAYAN, SHAHAB ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHAB
Middle Name:ROBERT
Last Name:BANAYAN
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 1:1430 WARNALL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5333
Mailing Address - Country:US
Mailing Address - Phone:424-208-4428
Mailing Address - Fax:
Practice Address - Street 1:6801 COLDWATER CANYON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-5162
Practice Address - Country:US
Practice Address - Phone:818-763-8836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine