Provider Demographics
NPI:1508421488
Name:SHAH, SMIT PRAFULCHANDRA (MD)
Entity Type:Individual
Prefix:
First Name:SMIT
Middle Name:PRAFULCHANDRA
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 1:1800 KILLIAN LAKES DR APT 16109
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8880
Mailing Address - Country:US
Mailing Address - Phone:856-649-2994
Mailing Address - Fax:
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR STE 420
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8004
Practice Address - Country:US
Practice Address - Phone:856-649-2994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCLL845102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program