Provider Demographics
NPI:1184804163
Name:SHAHAB M. EHTESHAM MD PLLC
Entity type:Organization
Organization Name:SHAHAB M. EHTESHAM MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHAB
Authorized Official - Middle Name:M
Authorized Official - Last Name:EHTESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-679-4200
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-0386
Mailing Address - Country:US
Mailing Address - Phone:276-679-4200
Mailing Address - Fax:276-679-4230
Practice Address - Street 1:611 TRENT ST NE
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1533
Practice Address - Country:US
Practice Address - Phone:276-679-4200
Practice Address - Fax:276-679-4230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101225223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08960Medicare PIN