Healthcare Provider Details

I. General information

NPI: 1255463576
Provider Name (Legal Business Name): SHAWNI S MOSHIRI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W CERMAK RD
CHICAGO IL
60623-3513
US

IV. Provider business mailing address

PO BOX 11232
CHICAGO IL
60611-0232
US

V. Phone/Fax

Practice location:
  • Phone: 312-550-0224
  • Fax: 773-376-9211
Mailing address:
  • Phone: 312-550-0224
  • Fax: 773-376-9211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-004154
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: