Provider Demographics
NPI:1174500664
Name:SHAH, PRIYAMVADA N (MD)
Entity Type:Individual
Prefix:
First Name:PRIYAMVADA
Middle Name:N
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRIYA
Other - Middle Name:N
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8911 LIBERTY MILLS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6311
Mailing Address - Country:US
Mailing Address - Phone:260-373-9465
Mailing Address - Fax:260-266-9406
Practice Address - Street 1:8911 LIBERTY MILLS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6311
Practice Address - Country:US
Practice Address - Phone:260-373-9465
Practice Address - Fax:260-266-9406
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029161A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000111784OtherANTHEM
IN0000002003211OtherANTHEM
IN100051620Medicaid
IN1845OtherPHYSICIANS HEALTH PLAN
IN3937240003OtherMEDICARE DMEPOS
4052315OtherAETNA
080130031OtherRAILROAD MEDICARE
IN070840AMedicare PIN
IN069860HMedicare PIN
IND67782Medicare UPIN