Provider Demographics
NPI:1447576186
Name:SHAH, MANJOOL M (MD)
Entity Type:Individual
Prefix:
First Name:MANJOOL
Middle Name:M
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 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:3181 EAST GRAND BLANC RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-694-6933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108690207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program