Provider Demographics
NPI:1619080843
Name:SHAN, KESAVAN (MD, FACC)
Entity Type:Individual
Prefix:DR
First Name:KESAVAN
Middle Name:
Last Name:SHAN
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16651 SOUTHWEST FREEWAY MOB1
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479
Mailing Address - Country:US
Mailing Address - Phone:281-275-0330
Mailing Address - Fax:281-275-0331
Practice Address - Street 1:16651 SOUTHWEST FREEWAY MOB1
Practice Address - Street 2:SUITE 450
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-275-0330
Practice Address - Fax:281-275-0331
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1925207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116637302Medicaid
TX116637305Medicaid
TXP01030497OtherRR MEDICARE
TX1619080843OtherBLUE CROSS BLUE SHIELD
TX060062836OtherRAILROAD MEDICARE
TX116637306Medicaid
TX116637308Medicaid
TXP00958397OtherMEDICARE RR
TXG95660Medicare UPIN
TX258307YQ64Medicare PIN
TX116637302Medicaid
TX116637306Medicaid
TX84961KMedicare PIN
TX258307YKWUMedicare PIN
TX258307YMVQMedicare PIN