Provider Demographics
NPI:1194829721
Name:SHAH, MUKUND K (MD)
Entity Type:Individual
Prefix:
First Name:MUKUND
Middle Name:K
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:STRECKER CANCER CENTER
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1644
Practice Address - Country:US
Practice Address - Phone:740-376-5000
Practice Address - Fax:740-376-5002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13835207RH0003X
OH35050858207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000525667OtherANTHEM
OHP00997169OtherRRMCR
WV0085338000Medicaid
OH000000696927OtherANTHEM
OH0549213Medicaid
OH000000696927OtherANTHEM
OH000000525667OtherANTHEM
WVD97153Medicare UPIN
OH7418641Medicare PIN