Provider Demographics
NPI:1043254170
Name:SHAH, SHIMUL Y (OD)
Entity Type:Individual
Prefix:
First Name:SHIMUL
Middle Name:Y
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1106
Mailing Address - Country:US
Mailing Address - Phone:937-642-1300
Mailing Address - Fax:937-642-0101
Practice Address - Street 1:122 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1106
Practice Address - Country:US
Practice Address - Phone:937-642-1300
Practice Address - Fax:937-642-0101
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH5091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1316122724OtherMEDICARE GROUP PTAN H213270
OH1043254170OtherMEDICARE INDIVIDUAL PTAN H213271
OH2636099Medicaid
OHSH4121281Medicare ID - Type Unspecified
OH1316122724OtherMEDICARE GROUP PTAN H213270
OHSH4121282Medicare ID - Type Unspecified