Provider Demographics
NPI:1366652208
Name:SHAKOURI, ALIREZA ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:ALIREZA
Middle Name:ALLEN
Last Name:SHAKOURI
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 1:900 E SOUTHLAKE BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6375
Mailing Address - Country:US
Mailing Address - Phone:817-421-0770
Mailing Address - Fax:817-421-4759
Practice Address - Street 1:900 E SOUTHLAKE BLVD
Practice Address - Street 2:STE 300
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6375
Practice Address - Country:US
Practice Address - Phone:817-421-0770
Practice Address - Fax:817-424-8431
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2294174400000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0026163OtherINSTITUTIONAL PERMIT