Provider Demographics
NPI:1811229107
Name:SHAHANAVAZ, SHABANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHABANA
Middle Name:
Last Name:SHAHANAVAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:NWT 8328 CB 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-6095
Mailing Address - Fax:314-454-2561
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:MLC 2003
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4432
Practice Address - Fax:513-636-3952
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY543082080P0202X
MO20110315142080P0202X
IN01092178A2080P0202X
OH35.1401612080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1811229107Medicaid