Provider Demographics
NPI:1164787131
Name:SHAH, DIPAM KIRAN (MD)
Entity Type:Individual
Prefix:
First Name:DIPAM
Middle Name:KIRAN
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 1:500 FOX HILLS DR N APT 8
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1339
Mailing Address - Country:US
Mailing Address - Phone:714-724-4521
Mailing Address - Fax:714-964-7852
Practice Address - Street 1:44405 WOODWARD AVENUE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-858-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine