Healthcare Provider Details

I. General information

NPI: 1972094878
Provider Name (Legal Business Name): MAHMOUD SHADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 12TH AVE NW STE 103
ARDMORE OK
73401-5762
US

IV. Provider business mailing address

5961 W PARKER RD APT 1107
PLANO TX
75093-7715
US

V. Phone/Fax

Practice location:
  • Phone: 580-220-6180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number50321
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: