Provider Demographics
NPI:1114121571
Name:SHAKIBA, KHASHAYAR (MD)
Entity Type:Individual
Prefix:
First Name:KHASHAYAR
Middle Name:
Last Name:SHAKIBA
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 1:173 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4001
Mailing Address - Country:US
Mailing Address - Phone:201-301-2772
Mailing Address - Fax:201-882-8422
Practice Address - Street 1:1 KALISA WAY STE 103
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3508
Practice Address - Country:US
Practice Address - Phone:201-301-2772
Practice Address - Fax:201-882-8422
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08288700207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ117463W9XMedicare PIN