Healthcare Provider Details

I. General information

NPI: 1396240925
Provider Name (Legal Business Name): BEENA MANISH SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SWEETBRIAR DR
COLUMBUS TX
78934-3008
US

IV. Provider business mailing address

100 SWEETBRIAR DR
COLUMBUS TX
78934-3008
US

V. Phone/Fax

Practice location:
  • Phone: 979-732-5771
  • Fax: 979-732-6922
Mailing address:
  • Phone: 979-732-5771
  • Fax: 979-732-6922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberU3010
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: