Provider Demographics
NPI:1184660813
Name:SHAH, KIRIT S (MD)
Entity Type:Individual
Prefix:
First Name:KIRIT
Middle Name:S
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 1:171 NE 102ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4169
Mailing Address - Country:US
Mailing Address - Phone:503-254-6418
Mailing Address - Fax:503-254-1029
Practice Address - Street 1:171 NE 102ND AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4169
Practice Address - Country:US
Practice Address - Phone:503-254-6418
Practice Address - Fax:503-254-1029
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12620208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226662Medicaid
OR226662Medicaid
ORR0000BKZBRMedicare ID - Type Unspecified