Provider Demographics
NPI:1881693703
Name:NADERI, SHAHROKH (MD, MPH, PSC)
Entity type:Individual
Prefix:
First Name:SHAHROKH
Middle Name:
Last Name:NADERI
Suffix:
Gender:M
Credentials:MD, MPH, PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2712
Mailing Address - Country:US
Mailing Address - Phone:270-826-0838
Mailing Address - Fax:270-830-0371
Practice Address - Street 1:1023 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2712
Practice Address - Country:US
Practice Address - Phone:270-826-0838
Practice Address - Fax:270-830-0371
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31902207V00000X
IN01044879A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64319023Medicaid
KY1640501Medicare ID - Type Unspecified
F40934Medicare UPIN