Provider Demographics
NPI:1124088380
Name:DERAKHSHAN, IRAJ (MD)
Entity type:Individual
Prefix:DR
First Name:IRAJ
Middle Name:
Last Name:DERAKHSHAN
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 1:1206 QUARRIER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1810
Mailing Address - Country:US
Mailing Address - Phone:304-343-4098
Mailing Address - Fax:304-343-4598
Practice Address - Street 1:1206 QUARRIER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1810
Practice Address - Country:US
Practice Address - Phone:304-343-4098
Practice Address - Fax:304-343-4598
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000102711OtherBCBS
WV0090508000Medicaid
WVDE0837504Medicare PIN
WVA78007Medicare UPIN