Healthcare Provider Details

I. General information

NPI: 1811229107
Provider Name (Legal Business Name): SHABANA SHAHANAVAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE MLC 2003
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

1 CHILDRENS PL NWT 8328 CB 8116
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4432
  • Fax: 513-636-3952
Mailing address:
  • Phone: 314-454-6095
  • Fax: 314-454-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number54308
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number2011031514
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number01092178A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number35.140161
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: