Provider Demographics
NPI:1326610015
Name:SHAKIBAKHO, SOROUSH (MD)
Entity type:Individual
Prefix:
First Name:SOROUSH
Middle Name:
Last Name:SHAKIBAKHO
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:PO BOX 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-0690
Mailing Address - Country:US
Mailing Address - Phone:330-363-7444
Mailing Address - Fax:330-363-7770
Practice Address - Street 1:6046 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7616
Practice Address - Country:US
Practice Address - Phone:330-433-1311
Practice Address - Fax:330-477-7783
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.150765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine