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
StateLicense IDTaxonomies
VA0101238418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010190495Medicaid
VA010318912Medicaid
VA010243947Medicaid
VA010190495Medicaid
VA010243947Medicaid
010978B85Medicare PIN
008224C47Medicare ID - Type Unspecified
VA010978B85Medicare PIN