Healthcare Provider Details

I. General information

NPI: 1841480274
Provider Name (Legal Business Name): KIANOUSH SHEYKHOLESLAMI MD. PHD.FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 EASTON AVE
NEW BRUNSWICK NJ
08901-1766
US

IV. Provider business mailing address

254 EASTON AVE
NEW BRUNSWICK NJ
08901-1766
US

V. Phone/Fax

Practice location:
  • Phone: 732-745-8600
  • Fax:
Mailing address:
  • Phone: 732-745-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number25MA09513900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number25MA09513900
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number25MA09513900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: