Provider Demographics
NPI:1083663306
Name:SHAH, SHISHIR (DO)
Entity Type:Individual
Prefix:
First Name:SHISHIR
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 W DUNLAP AVE
Mailing Address - Street 2:STE 290
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2759
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-789-8389
Practice Address - Street 1:2510 W DUNLAP AVE
Practice Address - Street 2:STE 290
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2759
Practice Address - Country:US
Practice Address - Phone:602-789-0344
Practice Address - Fax:602-789-8389
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ619348Medicaid
AZZ148196Medicare PIN
AZH11779Medicare UPIN