Provider Demographics
NPI:1407059710
Name:SHAH, SIDDHARTH P (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDDHARTH
Middle Name:P
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 1:3400 SPRUCE STREET
Mailing Address - Street 2:1 FOUNDERS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-2638
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:1 FOUNDERS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118148207R00000X
PAMD439711207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine