Provider Demographics
NPI:1073585683
Name:SHAH, CHANDRAKANT S (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRAKANT
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:PO BOX 30716
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-0716
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:6847 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-047623208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0563877Medicaid
OH000000142791OtherANTHEM
OH7234721Medicare ID - Type Unspecified
OH0563877Medicaid