Healthcare Provider Details

I. General information

NPI: 1720337850
Provider Name (Legal Business Name): MITRA ESHGHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 CENTERVILLE TPKE S
CHESAPEAKE VA
23322-3907
US

IV. Provider business mailing address

508 FAIR OAK DR
CHESAPEAKE VA
23322-1270
US

V. Phone/Fax

Practice location:
  • Phone: 757-482-4877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202211058
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19295
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: