1144283029 NPI number — SHAHAB M EHTESHAM MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144283029 NPI number — SHAHAB M EHTESHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EHTESHAM
Provider First Name:
SHAHAB
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144283029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 386
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WISE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-679-4200
Provider Business Mailing Address Fax Number:
276-679-4230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 TRENT ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24273-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-679-4200
Provider Business Practice Location Address Fax Number:
276-679-4230
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  32845 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0101225223 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010287669 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com