Provider Demographics
NPI:1336760677
Name:CHERAGHLOU, SHAYAN (MD)
Entity type:Individual
Prefix:
First Name:SHAYAN
Middle Name:
Last Name:CHERAGHLOU
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-1640
Mailing Address - Country:US
Mailing Address - Phone:215-460-2117
Mailing Address - Fax:
Practice Address - Street 1:725 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-1640
Practice Address - Country:US
Practice Address - Phone:276-326-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709528390200000X
VA0101285793207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program