Provider Demographics
NPI:1811341183
Name:FOROOTAN, SHAHLA (MD)
Entity type:Individual
Prefix:
First Name:SHAHLA
Middle Name:
Last Name:FOROOTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAHLA
Other - Middle Name:
Other - Last Name:FOROOTAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:34 N FRENCH PL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-6257
Mailing Address - Country:US
Mailing Address - Phone:928-778-4629
Mailing Address - Fax:928-778-4629
Practice Address - Street 1:34 N FRENCH PL
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-6257
Practice Address - Country:US
Practice Address - Phone:928-778-4629
Practice Address - Fax:928-778-4629
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15747261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care