Healthcare Provider Details

I. General information

NPI: 1447357223
Provider Name (Legal Business Name): ALICIA SHIRAKBARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICIA SHIRAKBARI-LESLIE MD

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 DANIEL DR
DANVILLE KY
40422-2527
US

IV. Provider business mailing address

431 FAYETTE PARK
LEXINGTON KY
40508-1330
US

V. Phone/Fax

Practice location:
  • Phone: 859-238-0018
  • Fax:
Mailing address:
  • Phone: 312-375-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number99000262A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01052776A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number41540
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-096107
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number41540
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: