Provider Demographics
NPI:1306876123
Name:KHORRAMI, SHAHRAM (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:KHORRAMI
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 1:9525 MONTE VISTA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2231
Mailing Address - Country:US
Mailing Address - Phone:909-626-1205
Mailing Address - Fax:
Practice Address - Street 1:9525 MONTE VISTA AVE STE 105
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2231
Practice Address - Country:US
Practice Address - Phone:909-626-1205
Practice Address - Fax:909-625-1977
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111325207RP1001X, 207RP1001X
NY236642207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADH722ZMedicare PIN
CADH722YMedicare PIN