Healthcare Provider Details

I. General information

NPI: 1184762122
Provider Name (Legal Business Name): SHOBHA R WANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 GOVERNORS PLACE BLVD SUITE 110
DAYTON OH
45409-1323
US

IV. Provider business mailing address

3075 GOVERNORS PLACE BLVD SUITE 110
DAYTON OH
45409-1323
US

V. Phone/Fax

Practice location:
  • Phone: 937-296-0015
  • Fax: 937-296-0074
Mailing address:
  • Phone: 937-296-0015
  • Fax: 937-296-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number35076738
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: