Provider Demographics
NPI:1932272804
Name:GHOLAMI, SHAHRAM SHAWN (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:SHAWN
Last Name:GHOLAMI
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 1:2460 SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3907
Mailing Address - Country:US
Mailing Address - Phone:408-358-2030
Mailing Address - Fax:408-358-2039
Practice Address - Street 1:2460 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3907
Practice Address - Country:US
Practice Address - Phone:408-358-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA650992088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A650991Medicare ID - Type Unspecified
H71217Medicare UPIN