Healthcare Provider Details

I. General information

NPI: 1174904981
Provider Name (Legal Business Name): SIAVASH DAVID SHAHBODAGHI MD/MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AVENUE N
HASKELL TX
79521-5415
US

IV. Provider business mailing address

1 AVENUE N
HASKELL TX
79521-5415
US

V. Phone/Fax

Practice location:
  • Phone: 940-228-4321
  • Fax:
Mailing address:
  • Phone: 940-228-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR8826
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: