Provider Demographics
NPI:1497940159
Name:SHAH, NISHANT
Entity Type:Individual
Prefix:
First Name:NISHANT
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 S COLLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2013
Mailing Address - Country:US
Mailing Address - Phone:925-863-9621
Mailing Address - Fax:347-763-8386
Practice Address - Street 1:330 N HOWARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3610
Practice Address - Country:US
Practice Address - Phone:410-576-1414
Practice Address - Fax:410-385-2762
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD79853207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty