Healthcare Provider Details

I. General information

NPI: 1730563594
Provider Name (Legal Business Name): SYED RAZA ALI SHAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2015
Last Update Date: 07/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W CHARLESTON BLVD SUITE 230
LAS VEGAS NV
89102-2325
US

IV. Provider business mailing address

1701 W CHARLESTON BLVD SUITE 230
LAS VEGAS NV
89102-2325
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-2345
  • Fax: 702-671-2376
Mailing address:
  • Phone: 702-671-2345
  • Fax: 702-671-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL2716
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: