Provider Demographics
NPI:1093703076
Name:SHAREGHI, KHOSRO (MD, FACC)
Entity Type:Individual
Prefix:DR
First Name:KHOSRO
Middle Name:
Last Name:SHAREGHI
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 OPITZ BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3321
Mailing Address - Country:US
Mailing Address - Phone:703-494-5995
Mailing Address - Fax:703-491-9153
Practice Address - Street 1:2200 OPITZ BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3321
Practice Address - Country:US
Practice Address - Phone:703-494-5995
Practice Address - Fax:703-491-9153
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042990174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA028690OtherANTHEM VIRGINIA
028689OtherHEALTHKEEPERS
541739580OtherTRICARE
60-2983-3OtherFIRST HEALTH
1475-0001OtherCAREFIRST
VA006029833Medicaid
4252028OtherAETNA
VA006029833Medicaid
4252028OtherAETNA