Provider Demographics
NPI:1477538783
Name:SHAH, GHAZANFAR A (MD)
Entity Type:Individual
Prefix:DR
First Name:GHAZANFAR
Middle Name:A
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:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-0906
Mailing Address - Country:US
Mailing Address - Phone:814-371-1784
Mailing Address - Fax:814-371-4812
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-371-1784
Practice Address - Fax:814-371-4812
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021477E2085N0904X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
P022732OtherTRICARE CLASS
300036814OtherRR MEDICARE CLASS
099132OtherBLUE SHIELD CLASS
30006409OtherKEYSTONE MERCY CLASS
39972OtherGEISINGER CLASS
PA0014331420001Medicaid
020636100OtherBLACK LUNG CLASS
1462168OtherUMWA CLASS
0014331420001OtherION HEALTH
206361OtherBLACK LUNG DETERMIN
300036814OtherRR MEDICARE CLASS
206361OtherBLACK LUNG DETERMIN