Provider Demographics
NPI:1649492679
Name:SHAH, MUDITA (MD)
Entity type:Individual
Prefix:
First Name:MUDITA
Middle Name:
Last Name:SHAH
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 1:800 8TH AVE
Mailing Address - Street 2:SUITE 324
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2601
Mailing Address - Country:US
Mailing Address - Phone:817-810-9800
Mailing Address - Fax:
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:SUITE 324
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2601
Practice Address - Country:US
Practice Address - Phone:817-817-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2791207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology