Provider Demographics
NPI:1225655574
Name:SHAH, PRAJWOL (MD)
Entity Type:Individual
Prefix:
First Name:PRAJWOL
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 1:904 WEIRES AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7436
Mailing Address - Country:US
Mailing Address - Phone:410-907-5108
Mailing Address - Fax:
Practice Address - Street 1:12500 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6393
Practice Address - Country:US
Practice Address - Phone:240-964-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2023-08-15
Deactivation Date:2022-01-17
Deactivation Code:
Reactivation Date:2022-04-08
Provider Licenses
StateLicense IDTaxonomies
MDD0097480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine