Provider Demographics
NPI:1598725921
Name:BAHARLOU, SHAHLA (MD)
Entity Type:Individual
Prefix:
First Name:SHAHLA
Middle Name:
Last Name:BAHARLOU
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:PO BOX 28082
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-8082
Mailing Address - Country:US
Mailing Address - Phone:212-987-3100
Mailing Address - Fax:212-731-5210
Practice Address - Street 1:1440 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-659-8552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220628207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H78319Medicare UPIN
NY106AH1Medicare ID - Type Unspecified