Provider Demographics
NPI:1306161492
Name:MEKHOUBAD, SHAHRAM (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:MEKHOUBAD
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 1:484 TEMPLE HILL RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5557
Mailing Address - Country:US
Mailing Address - Phone:845-565-3700
Mailing Address - Fax:
Practice Address - Street 1:484 TEMPLE HILL RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-5557
Practice Address - Country:US
Practice Address - Phone:845-565-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400100950Medicare PIN