Provider Demographics
NPI:1083361281
Name:SHAH, SHAZAD
Entity Type:Individual
Prefix:
First Name:SHAZAD
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 1:6113 JEFJEN WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-5990
Mailing Address - Country:US
Mailing Address - Phone:916-607-6658
Mailing Address - Fax:
Practice Address - Street 1:6113 JEFJEN WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-5990
Practice Address - Country:US
Practice Address - Phone:916-607-6658
Practice Address - Fax:916-378-0419
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver