Provider Demographics
NPI:1952300899
Name:SHAKOOR, TARIQ (MD)
Entity Type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:
Last Name:SHAKOOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3397
Mailing Address - Country:US
Mailing Address - Phone:513-853-4722
Mailing Address - Fax:513-852-8525
Practice Address - Street 1:1836 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5429
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32055207RG0100X
OH35.048678207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0675854Medicaid
IN100378150Medicaid
KY64864721Medicaid
OH110083909OtherRAILROAD MEDICARE
IN110086575OtherRAILROAD MEDICARE
OH0603211Medicare PIN
KY64864721Medicaid
OH110083909OtherRAILROAD MEDICARE