Provider Demographics
NPI:1043689755
Name:SHAH, DHRUVA
Entity Type:Individual
Prefix:DR
First Name:DHRUVA
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 1:1202 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2976
Mailing Address - Country:US
Mailing Address - Phone:505-367-3594
Mailing Address - Fax:
Practice Address - Street 1:1202 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2976
Practice Address - Country:US
Practice Address - Phone:505-367-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP0000813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist