Provider Demographics
NPI:1316180359
Name:ETEZADI-AMOLI, SHAHIN (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:SHAHIN
Middle Name:
Last Name:ETEZADI-AMOLI
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-5553
Mailing Address - Country:US
Mailing Address - Phone:972-412-4222
Mailing Address - Fax:
Practice Address - Street 1:5001 STATESMAN DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2414
Practice Address - Country:US
Practice Address - Phone:800-685-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2474208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics