Healthcare Provider Details

I. General information

NPI: 1952985541
Provider Name (Legal Business Name): SHEZAAN MOMIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 12/13/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 RED RIVER ST
AUSTIN TX
78701-1918
US

IV. Provider business mailing address

9808 BADEN LN
AUSTIN TX
78754-5516
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-7390
  • Fax:
Mailing address:
  • Phone: 512-820-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD.45229
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: