Healthcare Provider Details

I. General information

NPI: 1710122940
Provider Name (Legal Business Name): SHIBA KHORSANDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HENRICO DOCTORS HOSPITAL 1602 SKIPWITH RD
RICHMOND VA
23229-5205
US

IV. Provider business mailing address

5240 DRYSTACK LN
GLEN ALLEN VA
23059-5830
US

V. Phone/Fax

Practice location:
  • Phone: 804-280-4500
  • Fax:
Mailing address:
  • Phone: 908-514-5335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0101261758
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: