Basic Information
| Provider Information | |||||||||
| NPI: | 1821230319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | AVANTHI | ||||||||
| MiddleName: | TAYI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYI | ||||||||
| OtherFirstName: | AVANTHI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144562382 | ||||||||
| FaxNumber: | 2144566133 | ||||||||
| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753901811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144562382 | ||||||||
| FaxNumber: | 2144566133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2009 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A124972 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | P3978 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | A124972 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0207X | P3978 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
No ID Information.