Provider Demographics
NPI:1043228463
Name:GAVANDE, SHAILA SAMPAT (MD)
Entity Type:Individual
Prefix:
First Name:SHAILA
Middle Name:SAMPAT
Last Name:GAVANDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 UPVALLEY COURT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-451-1400
Mailing Address - Fax:512-451-1400
Practice Address - Street 1:2245 58TH ST
Practice Address - Street 2:THOMAS MOORE HEALTH CLINIC
Practice Address - City:FORTWORTH
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-285-6269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4348208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE4348OtherTEXAS LICENSE
E79952Medicare UPIN