Healthcare Provider Details

I. General information

NPI: 1336760677
Provider Name (Legal Business Name): SHAYAN CHERAGHLOU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 06/12/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S COLLEGE AVE
BLUEFIELD VA
24605-1640
US

IV. Provider business mailing address

725 S COLLEGE AVE
BLUEFIELD VA
24605-1640
US

V. Phone/Fax

Practice location:
  • Phone: 276-326-3376
  • Fax:
Mailing address:
  • Phone: 215-460-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35110
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number81146
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number709528
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101285793
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: