Provider Demographics
NPI:1073889002
Name:SHAH, NIKITA MUKESH (MD)
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:MUKESH
Last Name:SHAH
Suffix:
Gender:F
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 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:425 HAALAND DR STE 101
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-5230
Practice Address - Country:US
Practice Address - Phone:805-496-2949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR7322208600000X
MI4301112575208600000X
390200000X
CAA1700652086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX387124602Medicaid
TX387124602Medicaid