Provider Demographics
NPI:1710122940
Name:KHORSANDI, SHIBA
Entity Type:Individual
Prefix:
First Name:SHIBA
Middle Name:
Last Name:KHORSANDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 DRYSTACK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5830
Mailing Address - Country:US
Mailing Address - Phone:908-514-5335
Mailing Address - Fax:
Practice Address - Street 1:HENRICO DOCTORS HOSPITAL
Practice Address - Street 2:1602 SKIPWITH RD
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-280-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261758207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology