Provider Demographics
NPI:1376595272
Name:SHAH, RAJESH PUNJALAL (MD)
Entity Type:Individual
Prefix:
First Name:RAJESH
Middle Name:PUNJALAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-788-6760
Mailing Address - Fax:517-788-3029
Practice Address - Street 1:110 ELM ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9108
Practice Address - Country:US
Practice Address - Phone:517-788-6760
Practice Address - Fax:517-788-3029
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301048647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104522961Medicaid
MI80155461OtherRR MEDICARE
MIB45404Medicare UPIN
MI104522961Medicaid