Healthcare Provider Details

I. General information

NPI: 1598007676
Provider Name (Legal Business Name): AVNI A SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 CLEVELAND AVE STE 100
SANTA ROSA CA
95403-2122
US

IV. Provider business mailing address

3035 CLEVELAND AVE STE 100
SANTA ROSA CA
95403-3037
US

V. Phone/Fax

Practice location:
  • Phone: 708-623-8200
  • Fax:
Mailing address:
  • Phone: 707-546-9800
  • Fax: 707-899-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number269995
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA163015
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number269995
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberA163015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: