Provider Demographics
NPI:1902024987
Name:TAVACKOLI, SHAHIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHIN
Middle Name:
Last Name:TAVACKOLI
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 1:925 GESSNER RD
Mailing Address - Street 2:SUITE 630
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024
Mailing Address - Country:US
Mailing Address - Phone:713-465-3535
Mailing Address - Fax:713-465-9735
Practice Address - Street 1:925 GESSNER RD
Practice Address - Street 2:SUITE 630
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024
Practice Address - Country:US
Practice Address - Phone:713-465-3535
Practice Address - Fax:713-465-9735
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8986207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170041101Medicaid
TX170041101Medicaid
TX00972WMedicare ID - Type UnspecifiedMEDICARE GROUP