Provider Demographics
NPI:1023019882
Name:SHAH, RAJU S (MD)
Entity Type:Individual
Prefix:
First Name:RAJU
Middle Name:S
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 MONCLOVA RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1875
Mailing Address - Country:US
Mailing Address - Phone:419-893-2622
Mailing Address - Fax:
Practice Address - Street 1:5705 MONCLOVA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1875
Practice Address - Country:US
Practice Address - Phone:419-893-2622
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OH35-03-6372-S208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0392632Medicaid
OHSHO4322212Medicare ID - Type Unspecified
OH0392632Medicaid