Provider Demographics
NPI:1942377742
Name:VAKILI, SHAHLA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHLA
Middle Name:
Last Name:VAKILI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHAHLA
Other - Middle Name:
Other - Last Name:MOUSARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5401 OLD YORK ROAD
Mailing Address - Street 2:KLEIN 401
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3030
Mailing Address - Country:US
Mailing Address - Phone:215-456-7190
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:1500 LOCUST STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:610-331-6942
Practice Address - Fax:215-875-8324
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD433112084N0400X
DE18602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100853575000Medicaid
PA100853575000Medicaid
D01163Medicare UPIN