Provider Demographics
NPI:1922034487
Name:SHAFIEI, KHALED (MD)
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:SHAFIEI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 MEDICAL PARK DR.
Mailing Address - Street 2:SUITE 9
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203
Mailing Address - Country:US
Mailing Address - Phone:318-388-6050
Mailing Address - Fax:318-998-3022
Practice Address - Street 1:3510 MEDICAL PARK DR.
Practice Address - Street 2:SUITE 9
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203
Practice Address - Country:US
Practice Address - Phone:318-388-6050
Practice Address - Fax:318-998-3022
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026713207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1423521Medicaid
LAH96941Medicare UPIN
LA1423521Medicaid