Healthcare Provider Details

I. General information

NPI: 1942793708
Provider Name (Legal Business Name): SHAZAD ASHRAF BUKSH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 03/05/2023
Certification Date: 03/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1797 TIMBERLINE LN SE
SALEM OR
97306-9564
US

IV. Provider business mailing address

1797 TIMBERLINE LN SE
SALEM OR
97306-9564
US

V. Phone/Fax

Practice location:
  • Phone: 833-462-2692
  • Fax: 833-342-1173
Mailing address:
  • Phone: 833-469-2692
  • Fax: 833-342-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO61157008
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP-262
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP197850
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: