MEDICARE: DR. AVANTHI TAYI SHAH MD

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	208000000X	Pediatrics Physician	A124972	CA
2	208000000X	Pediatrics Physician	P3978	TX
3	2080P0207X	Pediatric Hematology & Oncology Physician	A124972	CA
4	2080P0207X	Pediatric Hematology & Oncology Physician	P3978	TX

General Provider Information

NPI Number	:	1821230319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AVANTHI TAYI SHAH MD

Provider Business Mailing Address
First Line	:	PO BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-456-2382
Fax Number	:	214-456-6133

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-1811
Country	:	US
Telephone Number	:	214-456-2382
Fax Number	:	214-456-6133

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

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	12/14/2020

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