Provider Demographics
NPI:1720039480
Name:SHAH, SYED NAYYAR (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:NAYYAR
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 1:1900 MISTLETOE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4048
Mailing Address - Country:US
Mailing Address - Phone:817-334-2800
Mailing Address - Fax:817-820-0094
Practice Address - Street 1:1900 MISTLETOE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4048
Practice Address - Country:US
Practice Address - Phone:817-338-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0931207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86466KOtherBCBS
TX10032328OtherAMERIGROUP
TX310501YT79OtherMEDICARE
TX1050387-02Medicaid
TX1050387-01Medicaid
TX5919753OtherAETNA PROVIDER ID
TX1050387-01Medicaid
TX5919753OtherAETNA PROVIDER ID
TX10032328OtherAMERIGROUP
TX86466KMedicare PIN
TX060062212Medicare PIN