Provider Demographics
NPI:1306191978
Name:SHAH, MIRAGE (OD)
Entity Type:Individual
Prefix:DR
First Name:MIRAGE
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7901
Mailing Address - Country:US
Mailing Address - Phone:410-571-8733
Mailing Address - Fax:410-571-6309
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:OPTHALMOLOGY CLINIC
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-5709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8314-TG152W00000X
PAOEG002675152W00000X
MDTA2615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8314OtherTEXAS OPTOMETRY BOARD
PAOEG002675OtherOPTOMETRY LICENSE NUMBER