1619080843 NPI number — DR. KESAVAN SHAN MD, FACC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619080843 NPI number — DR. KESAVAN SHAN MD, FACC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAN
Provider First Name:
KESAVAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, FACC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619080843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16651 SOUTHWEST FREEWAY MOB1
Provider Second Line Business Mailing Address:
SUITE 450
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-275-0330
Provider Business Mailing Address Fax Number:
281-275-0331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16651 SOUTHWEST FREEWAY MOB1
Provider Second Line Business Practice Location Address:
SUITE 450
Provider Business Practice Location Address City Name:
SUGAR LAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-275-0330
Provider Business Practice Location Address Fax Number:
281-275-0331
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  K1925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: K1925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: K1925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 116637302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116637305 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01030497 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1619080843 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 060062836 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 116637306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116637308 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00958397 . This is a "MEDICARE RR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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