Provider Demographics
NPI:1164509295
Name:BAGHERI, SHAHLA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHLA
Middle Name:
Last Name:BAGHERI
Suffix:
Gender:F
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:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-0696
Mailing Address - Country:US
Mailing Address - Phone:910-791-6767
Mailing Address - Fax:910-791-6890
Practice Address - Street 1:311-4E JUDGES ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3655
Practice Address - Country:US
Practice Address - Phone:914-967-8544
Practice Address - Fax:914-481-4758
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-015582084P0800X
NY143778174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912798Medicaid
NYB79448Medicare UPIN
NC5912798Medicaid
NC2075257Medicare PIN