Provider Demographics
NPI:1043273063
Name:SHAH, VIJAYA J (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:J
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIJAYA
Other - Middle Name:S
Other - Last Name:JADHAV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:862 SECOND STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1005
Mailing Address - Country:US
Mailing Address - Phone:215-322-9292
Mailing Address - Fax:215-322-4394
Practice Address - Street 1:862 SECOND STREET PIKE
Practice Address - Street 2:
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1005
Practice Address - Country:US
Practice Address - Phone:215-322-9292
Practice Address - Fax:215-322-4394
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037842L207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001034344Medicaid
PAC29702Medicare UPIN
PA001034344Medicaid