Provider Demographics
NPI:1255350104
Name:BIDIWALA, SHAAD B (MD)
Entity type:Individual
Prefix:
First Name:SHAAD
Middle Name:B
Last Name:BIDIWALA
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 1:6080 N CENTRAL EXPY STE 150
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-5202
Mailing Address - Country:US
Mailing Address - Phone:214-823-2052
Mailing Address - Fax:214-823-3797
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 907
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-823-2052
Practice Address - Fax:214-823-5747
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8619174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B9442Medicaid
TX00050NMedicare PIN
TX8B9442Medicaid