Provider Demographics
NPI:1174628978
Name:SHAH, SUDHA B (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:B
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 PERRYS HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-4253
Mailing Address - Country:US
Mailing Address - Phone:801-364-0685
Mailing Address - Fax:
Practice Address - Street 1:3460 PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2049
Practice Address - Country:US
Practice Address - Phone:801-993-9526
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159957-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870532396SH1OtherEDUCATORS MUTUAL
UT2000130OtherUNITED HEALTHCARE
UT36702OtherDESERET MUTUAL
UTPR00677OtherMOLINA
UT53004OtherHEALTHY U
UTQM0000023692OtherALTIUS
UT107001105101OtherIHC
UT2000130OtherUNITED HEALTHCARE