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NPI Code Detail

MEDICARE: DR. SHOKOOH MIRY PSYD

MEDICARE: DR. SHOKOOH MIRY PSYD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist24343CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
124343OTHERCABOARD OF PSYCHOLOGY LICENSE

General Provider Information

NPI Number : 1396026381
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHOKOOH MIRY PSYD
Provider Business Mailing Address
First Line : 1 SANSOME ST FL 35
Second Line :
City : SAN FRANCISCO
State : CA
Zip : 94104-4436
Country : US
Telephone Number : 415-298-0122
Fax Number :
Provider Business Practice Location Address
First Line : 1 SANSOME ST FL 35
Second Line :
City : SAN FRANCISCO
State : CA
Zip : 94104-4436
Country : US
Telephone Number : 415-298-0122
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/02/2011
Last Update Date : 09/19/2013

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