Provider Demographics
NPI:1295824365
Name:KHORSHAD, MIRAFLOR G (MD)
Entity Type:Individual
Prefix:
First Name:MIRAFLOR
Middle Name:G
Last Name:KHORSHAD
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 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1343
Mailing Address - Country:US
Mailing Address - Phone:304-872-1663
Mailing Address - Fax:304-872-1804
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1343
Practice Address - Country:US
Practice Address - Phone:304-872-5500
Practice Address - Fax:304-872-5592
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049819000Medicaid
WVD49368Medicare UPIN
WVKH0540882Medicare ID - Type Unspecified