Basic Information
| Provider Information | |||||||||
| NPI: | 1528054046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIRVANI | ||||||||
| FirstName: | ALI | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 4325 N JOSEY LN STE 206 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149158515 | ||||||||
| FaxNumber: | 4698922312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | J7848 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 575375YNED | 01 | TX | MEDICARE DALLAS | OTHER | 575372YND4 | 01 | TX | MEDICARE 99 | OTHER | 575372YNEC | 01 | TX | MEDICARE - TARRANT | OTHER | 030698708 | 05 | TX | MEDICAID |