MEDICARE: KAVITA SANJIV SHAH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	K9415	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023088507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAVITA SANJIV SHAH M.D.

Provider Business Mailing Address
First Line	:	909 SOUTHEAST PKWY STE 105
Second Line	:
City	:	AZLE
State	:	TX
Zip	:	76020-3600
Country	:	US
Telephone Number	:	817-238-0735
Fax Number	:	817-238-7327

Provider Business Practice Location Address
First Line	:	909 SOUTHEAST PKWY STE 105
Second Line	:
City	:	AZLE
State	:	TX
Zip	:	76020-3600
Country	:	US
Telephone Number	:	817-238-0735
Fax Number	:	817-238-7327

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	10/23/2012

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