Healthcare Provider Details

I. General information

NPI: 1922034487
Provider Name (Legal Business Name): KHALED SHAFIEI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 MEDICAL PARK DR. SUITE 9
MONROE LA
71203
US

IV. Provider business mailing address

3510 MEDICAL PARK DR. SUITE 9
MONROE LA
71203
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-6050
  • Fax: 318-998-3022
Mailing address:
  • Phone: 318-388-6050
  • Fax: 318-998-3022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number026713
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number026713
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: