Healthcare Provider Details

I. General information

NPI: 1023088507
Provider Name (Legal Business Name): KAVITA SANJIV SHAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SOUTHEAST PKWY STE 105
AZLE TX
76020-3600
US

IV. Provider business mailing address

909 SOUTHEAST PKWY STE 105
AZLE TX
76020-3600
US

V. Phone/Fax

Practice location:
  • Phone: 817-238-0735
  • Fax: 817-238-7327
Mailing address:
  • Phone: 817-238-0735
  • Fax: 817-238-7327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK9415
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: