Provider Demographics
NPI: | 1497736748 |
---|---|
Name: | SHAH, MIKESH C (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MIKESH |
Middle Name: | C |
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: | 2740 CHATEAU CT |
Mailing Address - Street 2: | |
Mailing Address - City: | ROANOKE |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 24012-6782 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 540-977-4589 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 390 S MAIN ST |
Practice Address - Street 2: | SUITE 201 |
Practice Address - City: | ROCKY MOUNT |
Practice Address - State: | VA |
Practice Address - Zip Code: | 24151-1711 |
Practice Address - Country: | US |
Practice Address - Phone: | 540-484-4800 |
Practice Address - Fax: | 540-484-4882 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-11 |
Last Update Date: | 2012-03-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101238418 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 010190495 | Medicaid | |
VA | 010318912 | Medicaid | |
VA | 010243947 | Medicaid | |
VA | 010190495 | Medicaid | |
VA | 010243947 | Medicaid | |
010978B85 | Medicare PIN | ||
008224C47 | Medicare ID - Type Unspecified | ||
VA | 010978B85 | Medicare PIN |