Provider Demographics
NPI:1497753099
Name:SHAH, FATIMA S (DO)
Entity Type:Individual
Prefix:
First Name:FATIMA
Middle Name:S
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:315 SE STONE MILL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6998
Practice Address - Country:US
Practice Address - Phone:360-816-2700
Practice Address - Fax:360-816-2710
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00822615OtherRR MEDICARE
WA8942796OtherCRIME VICTIMS WA STATE
WA0214145OtherLABOR & IND. WA STATE
IN200334350Medicaid
OR240360Medicaid
WA8465619Medicaid
WAP00822615OtherRR MEDICARE
WA8862133Medicare PIN
H59502Medicare UPIN
IN200334350Medicaid