Healthcare Provider Details

I. General information

NPI: 1265844963
Provider Name (Legal Business Name): LEILI SHAHGHOLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 CEDAR ST
BROOKLYN NY
11221-3253
US

IV. Provider business mailing address

PO BOX 22239
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 201-654-6397
  • Fax: 201-608-9241
Mailing address:
  • Phone: 201-654-6397
  • Fax: 201-608-9241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number330773
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: