Healthcare Provider Details

I. General information

NPI: 1306876123
Provider Name (Legal Business Name): SHAHRAM KHORRAMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9525 MONTE VISTA AVE STE 105
MONTCLAIR CA
91763-2231
US

IV. Provider business mailing address

9525 MONTE VISTA AVE STE 105
MONTCLAIR CA
91763-2231
US

V. Phone/Fax

Practice location:
  • Phone: 909-626-1205
  • Fax: 909-625-1977
Mailing address:
  • Phone: 909-626-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA111325
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number236642
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: