Healthcare Provider Details

I. General information

NPI: 1003617291
Provider Name (Legal Business Name): MOHAMMAD SHIGRI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19460A 64TH AVE APT 2A
FRESH MEADOWS NY
11365-2837
US

IV. Provider business mailing address

19460A 64TH AVE APT 2A
FRESH MEADOWS NY
11365-2837
US

V. Phone/Fax

Practice location:
  • Phone: 516-547-7769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberEL7224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: