Provider Demographics
NPI:1164615589
Name:SHAH, ANISH SUNDERRAJAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANISH
Middle Name:SUNDERRAJAN
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:480 TESCONI CIR STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4691
Mailing Address - Country:US
Mailing Address - Phone:707-206-7268
Mailing Address - Fax:707-206-7254
Practice Address - Street 1:480 TESCONI CIR STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4691
Practice Address - Country:US
Practice Address - Phone:707-206-7268
Practice Address - Fax:707-206-7254
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA849922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry