Provider Demographics
NPI:1225193923
Name:SHAH, MUKESH (MD)
Entity Type:Individual
Prefix:
First Name:MUKESH
Middle Name:
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 1:1656 CHAMPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-724-4017
Mailing Address - Fax:
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-724-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153083207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33DO942942OtherCLIA LICENSE
NY153083OtherNY STATE LICESNSE
NY165131OtherMVP HEALTHCARE
NY00796901Medicaid
NY00796901Medicaid
NY165131OtherMVP HEALTHCARE