Provider Demographics
NPI:1275745465
Name:JAGDISH A. SHAH,MD
Entity Type:Organization
Organization Name:JAGDISH A. SHAH,MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAGDISH
Authorized Official - Middle Name:AMRATLAL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-583-7424
Mailing Address - Street 1:1220 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4017
Mailing Address - Country:US
Mailing Address - Phone:903-583-7424
Mailing Address - Fax:903-583-0442
Practice Address - Street 1:1220 EAST 6TH STREET
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418
Practice Address - Country:US
Practice Address - Phone:903-583-7424
Practice Address - Fax:903-583-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080892501Medicaid
TX080892501Medicaid
TX00621KMedicare ID - Type Unspecified