Healthcare Provider Details

I. General information

NPI: 1710953690
Provider Name (Legal Business Name): SHAHROKH CHARLES KHANI MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CUMMINGS CENTER SUITE 303V
BEVERLY MA
01915-6181
US

IV. Provider business mailing address

47 WALKER ROAD
MANCHESTER MA
01944-1632
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-1344
  • Fax: 978-922-1346
Mailing address:
  • Phone: 978-922-1344
  • Fax: 978-922-1346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number234349
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: