Provider Demographics
NPI:1265630230
Name:SHAH, KETUL K (MD)
Entity Type:Individual
Prefix:DR
First Name:KETUL
Middle Name:K
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5400 FRANTZ RD STE 250
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-6102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 POLARIS PKWY STE 2300
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7993
Practice Address - Country:US
Practice Address - Phone:614-788-2870
Practice Address - Fax:614-533-0177
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35121117208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085240Medicaid
OHP01249264OtherRAILROAD MEDICARE
OHH206400Medicare PIN