Healthcare Provider Details

I. General information

NPI: 1083159305
Provider Name (Legal Business Name): SHAYAN KHORSANDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA #2, KILOMETER 39.5 OFIC. 110
VEGA BAJA PR
00693
US

IV. Provider business mailing address

16 PLAZA SANTA CRUZ
TRUJILLO ALTO PR
00976-6123
US

V. Phone/Fax

Practice location:
  • Phone: 787-226-5425
  • Fax:
Mailing address:
  • Phone: 787-226-5425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA10177800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number021715
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: