Provider Demographics
NPI:1578192183
Name:SHAHROKH, SOROUSH (DO)
Entity Type:Individual
Prefix:
First Name:SOROUSH
Middle Name:
Last Name:SHAHROKH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TTUHSC 3601 4TH STREET MS 9410, OFFICE 4B076
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0001
Mailing Address - Country:US
Mailing Address - Phone:806-743-2040
Mailing Address - Fax:
Practice Address - Street 1:TTUHSC 3601 4TH STREET MS 9410, OFFICE 4B076
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-4412
Practice Address - Country:US
Practice Address - Phone:806-743-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXBP20083764390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program