Provider Demographics
NPI:1326782251
Name:PERVAZE, SHOHAN
Entity Type:Individual
Prefix:
First Name:SHOHAN
Middle Name:
Last Name:PERVAZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 34TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4998
Mailing Address - Country:US
Mailing Address - Phone:917-715-3180
Mailing Address - Fax:
Practice Address - Street 1:918 34TH AVE APT 1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-4998
Practice Address - Country:US
Practice Address - Phone:917-715-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116036243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine