Provider Demographics
NPI:1235486416
Name:SHAMBAYATI, MARYAM (DO)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:SHAMBAYATI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:405-713-7060
Mailing Address - Fax:405-713-7064
Practice Address - Street 1:3330 NW 56TH ST STE 500
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4470
Practice Address - Country:US
Practice Address - Phone:405-713-7060
Practice Address - Fax:405-713-7064
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1300208000000X
390200000X
OK58132080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30209771OtherTEXAS DPS
FS4903541OtherDEA