Provider Demographics
NPI:1659374080
Name:SHAH, HARIVADAN V (MD)
Entity Type:Individual
Prefix:
First Name:HARIVADAN
Middle Name:V
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 PARK CENTRAL DR
Mailing Address - Street 2:STE 430
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-1527
Mailing Address - Country:US
Mailing Address - Phone:972-239-8902
Mailing Address - Fax:972-661-2551
Practice Address - Street 1:12700 PARK CENTRAL DR
Practice Address - Street 2:STE 430
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-1527
Practice Address - Country:US
Practice Address - Phone:972-239-8902
Practice Address - Fax:972-661-2551
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG28412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNC21653Medicare UPIN
TX86R647Medicare ID - Type Unspecified