Provider Demographics
NPI:1861502627
Name:ROSHANRAVAN, SHAYZREEN M (MD)
Entity Type:Individual
Prefix:
First Name:SHAYZREEN
Middle Name:M
Last Name:ROSHANRAVAN
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 1:4700 DEXTER DR STE 400
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5299
Mailing Address - Country:US
Mailing Address - Phone:972-596-3242
Mailing Address - Fax:
Practice Address - Street 1:4700 DEXTER DR STE 400
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5299
Practice Address - Country:US
Practice Address - Phone:972-596-3242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4490207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184522407Medicaid
TX184522408Medicaid
TX184522405Medicaid
TX8L27442Medicare PIN
TX8L16057Medicare PIN
TX184522405Medicaid
TX8L13880Medicare PIN
TX184522407Medicaid
TXTXB100140Medicare PIN