Provider Demographics
NPI:1144204702
Name:SHAHKOHI, FARNOUSH (OD)
Entity Type:Individual
Prefix:DR
First Name:FARNOUSH
Middle Name:
Last Name:SHAHKOHI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MORRIS LN
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1707
Mailing Address - Country:US
Mailing Address - Phone:516-707-5145
Mailing Address - Fax:347-887-5000
Practice Address - Street 1:14 MORRIS LN
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11024-1707
Practice Address - Country:US
Practice Address - Phone:516-707-5145
Practice Address - Fax:347-887-5000
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV56006926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02707091Medicaid
NY02707091Medicaid
NYC432AWS861Medicare PIN
NYC432A68971Medicare PIN
NYV07850Medicare UPIN
NY02707091Medicaid