=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609872928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IHSAN FAHMI SHANTI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2005
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5611 BELLAIRE BLVD # 100
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77081-5617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-339-1566
-----------------------------------------------------
Fax | 713-465-5965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 N BRAESWOOD BLVD # 376
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77096-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-339-1566
-----------------------------------------------------
Fax | 713-339-1518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | K4562
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------