Provider Demographics
NPI:1356426316
Name:SHAKOOR, AHTISHAM (MD)
Entity type:Individual
Prefix:
First Name:AHTISHAM
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 1:1850 W FRYE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6232
Mailing Address - Country:US
Mailing Address - Phone:480-782-0101
Mailing Address - Fax:480-782-1251
Practice Address - Street 1:1850 W FRYE RD STE 101
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6232
Practice Address - Country:US
Practice Address - Phone:480-782-0101
Practice Address - Fax:480-782-1251
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27556207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ468646Medicaid
AZ468646Medicaid
AZF38402Medicare ID - Type Unspecified