Provider Demographics
NPI:1336282953
Name:SHAH, LISA JITENDRA (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JITENDRA
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W GIRARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-1531
Mailing Address - Country:US
Mailing Address - Phone:215-685-3808
Mailing Address - Fax:215-685-3848
Practice Address - Street 1:321 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1531
Practice Address - Country:US
Practice Address - Phone:215-685-3808
Practice Address - Fax:215-685-3848
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231392207Q00000X
PAOS014477207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY231392OtherLICENSE
NY02706081Medicaid
NYI34116Medicare UPIN
NY02706081Medicaid