Provider Demographics
NPI:1265452528
Name:SHAH, CHANDRESH R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDRESH
Middle Name:R
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 1:200 STATE HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-9198
Mailing Address - Country:US
Mailing Address - Phone:570-271-4500
Mailing Address - Fax:570-271-4802
Practice Address - Street 1:200 STATE HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-9198
Practice Address - Country:US
Practice Address - Phone:570-271-4500
Practice Address - Fax:570-271-4802
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030987E208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA416124KALMedicare ID - Type Unspecified
E45510Medicare UPIN