Healthcare Provider Details

I. General information

NPI: 1841934270
Provider Name (Legal Business Name): SHAHRZAD FAKHRAEE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 04/22/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 858-699-1346
  • Fax:
Mailing address:
  • Phone: 858-699-1346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number1-031-535-6
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: