Provider Demographics
NPI:1205851326
Name:SHAH, KANTI HIRALAL (MD)
Entity Type:Individual
Prefix:
First Name:KANTI
Middle Name:HIRALAL
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 1:814 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2930
Mailing Address - Country:US
Mailing Address - Phone:734-243-5720
Mailing Address - Fax:734-243-9261
Practice Address - Street 1:814 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2930
Practice Address - Country:US
Practice Address - Phone:734-243-5720
Practice Address - Fax:734-243-9261
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032767208000000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1054463Medicaid
MI1054463Medicaid
1586116Medicare ID - Type Unspecified