Provider Demographics
NPI:1770580425
Name:SHAFEI, MOHEDINE (MD)
Entity type:Individual
Prefix:DR
First Name:MOHEDINE
Middle Name:
Last Name:SHAFEI
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 1:106 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:GOODLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67735-1518
Mailing Address - Country:US
Mailing Address - Phone:785-890-6075
Mailing Address - Fax:785-890-6077
Practice Address - Street 1:106 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-1518
Practice Address - Country:US
Practice Address - Phone:785-890-6075
Practice Address - Fax:785-890-6077
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100147300BMedicaid
KS645460OtherFIRSTGUARD
KS103518Medicare ID - Type UnspecifiedBCBS
KSE97859Medicare UPIN