Provider Demographics
NPI:1710953690
Name:KHANI, SHAHROKH CHARLES (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:SHAHROKH
Middle Name:CHARLES
Last Name:KHANI
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WALKER ROAD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01944-1632
Mailing Address - Country:US
Mailing Address - Phone:978-922-1344
Mailing Address - Fax:978-922-1346
Practice Address - Street 1:900 CUMMINGS CENTER
Practice Address - Street 2:SUITE 303V
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6181
Practice Address - Country:US
Practice Address - Phone:978-922-1344
Practice Address - Fax:978-922-1346
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234349207WX0107X
NY2006691207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00020008502OtherUNIVERA
MA110084000AMedicaid
NY01592773Medicaid
NY0808437OtherIHA
NY005238835OtherBCBS
NY0808437OtherIHA
NY13003DMedicare ID - Type Unspecified