Provider Demographics
NPI:1477664308
Name:SHAH, JAY N (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:N
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAYPRAKASH
Other - Middle Name:N
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1520 N MOUNTAIN AVE
Mailing Address - Street 2:BULDING E, SUITE 205
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1128
Mailing Address - Country:US
Mailing Address - Phone:909-981-3039
Mailing Address - Fax:909-981-5935
Practice Address - Street 1:1520 N MOUNTAIN AVE
Practice Address - Street 2:BULDING E, SUITE 205
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1128
Practice Address - Country:US
Practice Address - Phone:909-981-3039
Practice Address - Fax:909-981-5935
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39867207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABC804XMedicare PIN
CAD69071Medicare UPIN
CA00A398671Medicare ID - Type Unspecified
CABC804WMedicare PIN