Provider Demographics
NPI:1720170657
Name:SHAKIR, KHUSRO NAZ
Entity type:Individual
Prefix:
First Name:KHUSRO
Middle Name:NAZ
Last Name:SHAKIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N JACKSON AVE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95115-1917
Mailing Address - Country:US
Mailing Address - Phone:408-923-8840
Mailing Address - Fax:408-258-0513
Practice Address - Street 1:135 N JACKSON AVE
Practice Address - Street 2:SUITE #103
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95115-1917
Practice Address - Country:US
Practice Address - Phone:408-923-8840
Practice Address - Fax:408-258-0513
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A452930Medicaid
CA00A452930Medicare ID - Type Unspecified
CA00A452930Medicaid