Provider Demographics
NPI:1447357223
Name:SHIRAKBARI, ALICIA (MD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:SHIRAKBARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:SHIRAKBARI-LESLIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:431 FAYETTE PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1330
Mailing Address - Country:US
Mailing Address - Phone:312-375-7575
Mailing Address - Fax:
Practice Address - Street 1:128 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2527
Practice Address - Country:US
Practice Address - Phone:859-238-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99000262A207P00000X
IN01052776A207P00000X
KY41540207P00000X, 2083A0300X
IL036-096107207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096107Medicaid
G80591Medicare UPIN