Provider Demographics
NPI:1396792602
Name:SHABNAM QASIM MDPA
Entity type:Organization
Organization Name:SHABNAM QASIM MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHABNAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:QASIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-626-9744
Mailing Address - Street 1:4819 RIVER OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76114
Mailing Address - Country:US
Mailing Address - Phone:817-626-9744
Mailing Address - Fax:817-626-9962
Practice Address - Street 1:4819 RIVER OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114
Practice Address - Country:US
Practice Address - Phone:817-626-9744
Practice Address - Fax:817-626-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1634057Medicaid
H11768Medicare UPIN
TX00346LMedicare ID - Type Unspecified