Healthcare Provider Details

I. General information

NPI: 1760592836
Provider Name (Legal Business Name): NIRAV J SHASTRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5808 W 110TH ST
OVERLAND PARK KS
66211-2504
US

IV. Provider business mailing address

2401 GILLHAM RD PROVIDER ENROLLMENT DEPARTMENT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 913-696-8000
  • Fax:
Mailing address:
  • Phone: 816-701-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number04-26827
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: