Provider Demographics
NPI:1003090663
Name:SHAH, MANSI (DO)
Entity Type:Individual
Prefix:
First Name:MANSI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUN LOOP
Mailing Address - Street 2:#210
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4515
Mailing Address - Fax:318-798-4578
Practice Address - Street 1:1455 E BERT KOUN LOOP
Practice Address - Street 2:#210
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-798-4515
Practice Address - Fax:318-798-4530
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPENDING207R00000X
TXN1445207RR0500X
LA300501207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2409051Medicaid
LA2409051Medicaid