Provider Demographics
NPI:1043310329
Name:SHAMS, MITRA (MD)
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:SHAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-238-2801
Mailing Address - Fax:502-238-2835
Practice Address - Street 1:6041 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8134
Practice Address - Country:US
Practice Address - Phone:502-228-2225
Practice Address - Fax:502-228-2226
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYTP723207R00000X
KY40284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000699132OtherANTHEM - NCMA
KY50031915OtherPASSPORT & PP ADVTG - NCMA
KY7659346OtherCIGNA - NCMA
KYP00893048OtherRAILROAD MEDICARE - KY
KY7100020180Medicaid
IN200859040Medicaid
KY121562OtherSIHO - NCMA
KY000057058TOtherHUMANA - NCMA
KY7659346OtherCIGNA - NCMA