Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0106X | Oral and Maxillofacial Pathology | OMS69 | CA |
N | 2086S0122X | Plastic and Reconstructive Surgery | A96072 | CA |
NPI | 1811107709 |
---|---|
Provider Name | Shahram Mashadian |
First Address | Victorville, CA 92395-7753 |
Second Address | Victorville, CA 92395-7753 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2007 |
Last Update Date | 08/07/2007 |