Provider Demographics
NPI:1700944378
Name:SHAMSI, SHAHRAD RADI (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAD
Middle Name:RADI
Last Name:SHAMSI
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 1:2021 SANTA MONICA BLVD STE 325E
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2149
Mailing Address - Country:US
Mailing Address - Phone:310-453-0504
Mailing Address - Fax:310-453-0520
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 325E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2149
Practice Address - Country:US
Practice Address - Phone:310-453-0504
Practice Address - Fax:310-453-0520
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA203305981OtherTIN
CAH51480Medicare UPIN
CAW19454Medicare ID - Type UnspecifiedMEDICARE GROUP I.D. #