Provider Demographics
NPI:1497854491
Name:SHAH, UDAYAN B (MD)
Entity Type:Individual
Prefix:DR
First Name:UDAYAN
Middle Name:B
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 1:11802 BELLS CHAPEL WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029
Mailing Address - Country:US
Mailing Address - Phone:410-531-3030
Mailing Address - Fax:
Practice Address - Street 1:3350 WILKENS AVENUE
Practice Address - Street 2:SUITE 307
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-644-2733
Practice Address - Fax:410-644-5213
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025522208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D74441Medicare UPIN
7819Medicare ID - Type Unspecified