Provider Demographics
NPI:1235568072
Name:SHAH, RUPAL BHAGAT (OD)
Entity Type:Individual
Prefix:
First Name:RUPAL
Middle Name:BHAGAT
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 S HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-4225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:193 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4209
Practice Address - Country:US
Practice Address - Phone:910-995-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009691-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ27OA00650500OtherSTATE LICENSE NUMBER