Provider Demographics
NPI:1487652152
Name:SHAH, RAJESH V (MD)
Entity Type:Individual
Prefix:
First Name:RAJESH
Middle Name:V
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 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:514 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2316
Practice Address - Country:US
Practice Address - Phone:812-676-4444
Practice Address - Fax:812-676-4445
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060022A207R00000X, 207RH0000X, 207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200506210Medicaid
IN200506210Medicaid
IN114620TTMedicare PIN
IN000000371315OtherANTHEM PIN (ICCC)
INP01059135Medicare PIN
IN200506210Medicaid
INP00457478Medicare PIN