Provider Demographics
NPI:1518287812
Name:SHAH, JEANINE CAROLINE (MD)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:CAROLINE
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 CAMPUS DR STE W225
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2752
Mailing Address - Country:US
Mailing Address - Phone:415-504-3838
Mailing Address - Fax:415-504-1367
Practice Address - Street 1:3033 CAMPUS DR STE W225
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2752
Practice Address - Country:US
Practice Address - Phone:415-504-3838
Practice Address - Fax:415-504-1367
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT075616207Q00000X
AZ47115207Q00000X
OH35.139958207Q00000X
IN01091768A207Q00000X
MS31930207Q00000X
IL036.132417207Q00000X
OK42055207Q00000X
IDMC-0656207Q00000X
MTMED-PHYS-COM-LIC-903207Q00000X
ORMD202531207Q00000X
AL43548207Q00000X
GA86307207Q00000X
WI1017-320207Q00000X
WAMD61092503207Q00000X
FLTPME327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine