Provider Demographics
NPI:1265845986
Name:SHAH, ANISH NITISH (MD)
Entity Type:Individual
Prefix:
First Name:ANISH
Middle Name:NITISH
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 1:2401 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303
Mailing Address - Country:US
Mailing Address - Phone:765-741-1515
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-741-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69222-20207R00000X
IL125065115390200000X
IN01078995A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program