Provider Demographics
NPI:1023263282
Name:MOUSAVI, SHAHRYAR (MD)
Entity type:Individual
Prefix:
First Name:SHAHRYAR
Middle Name:
Last Name:MOUSAVI
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 1:35 CREEK RD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4724
Mailing Address - Country:US
Mailing Address - Phone:315-464-4889
Mailing Address - Fax:949-679-1084
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:#3A
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4342
Practice Address - Country:US
Practice Address - Phone:949-297-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA128033208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB235450OtherMEDICARE PTAN