Basic Information
| Provider Information | |||||||||
| NPI: | 1275526048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOKOOHI | ||||||||
| FirstName: | FARHAD | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2393 SCHUST RD | ||||||||
| Address2: | GREAT LAKES EYE INSTITUTE | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486031334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897932820 | ||||||||
| FaxNumber: | 9897939132 | ||||||||
| Practice Location | |||||||||
| Address1: | 2393 SCHUST RD | ||||||||
| Address2: | GREAT LAKES EYE INSTITUTE | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486031334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897932820 | ||||||||
| FaxNumber: | 9897939132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 4301040619 | MI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0467800006 | 01 | ADMINASTAR | OTHER | 0467800002 | 01 | ADMINASTAR | OTHER | 2622510 | 05 | MI | MEDICAID | 0467800005 | 01 | ADMINASTAR | OTHER | 180G300890 | 01 | MI | BLUE CARE NETWORK | OTHER | 0467800001 | 01 | ADMINASTAR | OTHER | 1359493 | 05 | MI | MEDICAID | 180G300890 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 0467800004 | 01 | ADMINASTAR | OTHER | 4301040619 | 01 | MI | LICENSE NUMBER | OTHER | CA3610 | 01 | MI | RAILROAD MEDICARE | OTHER |