Provider Demographics
NPI:1003355264
Name:SHAH, MAYANK
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2900
Mailing Address - Country:US
Mailing Address - Phone:317-453-0430
Mailing Address - Fax:
Practice Address - Street 1:3250 W BIG BEAVER RD
Practice Address - Street 2:SUITE 304
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2900
Practice Address - Country:US
Practice Address - Phone:317-453-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist