Provider Demographics
NPI:1295180214
Name:SHOKOOHI, NICHOLAS DAVID (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DAVID
Last Name:SHOKOOHI
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 1:2393 SCHUST RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1334
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-755-1463
Practice Address - Street 1:2393 SCHUST RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1334
Practice Address - Country:US
Practice Address - Phone:989-793-2820
Practice Address - Fax:989-755-1463
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301502033207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301502033OtherPHYSICIAN LICENSE
MIFS9601445OtherDEA LICENSE