Provider Demographics
NPI:1265865034
Name:SHAH, GAUTAM VINOD (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:VINOD
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 1:20455 LORAIN RD FL 2
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3530
Mailing Address - Country:US
Mailing Address - Phone:216-408-1044
Mailing Address - Fax:
Practice Address - Street 1:20455 LORAIN RD FL 2
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126
Practice Address - Country:US
Practice Address - Phone:216-408-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.136566207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease