Healthcare Provider Details

I. General information

NPI: 1700103926
Provider Name (Legal Business Name): AVNI SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13625 RONALD W REAGAN BLVD BLDG 6
CEDAR PARK TX
78613-2073
US

IV. Provider business mailing address

3406 WHIRLAWAY DR
NORTHBROOK IL
60062-6363
US

V. Phone/Fax

Practice location:
  • Phone: 512-336-2777
  • Fax:
Mailing address:
  • Phone: 773-510-3682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP7704
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: