Provider Demographics
NPI:1518905348
Name:SHAH, MINDY S (MD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:S
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:JO
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:50 S B B KING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:866-949-0108
Mailing Address - Fax:
Practice Address - Street 1:5395 E CHERYL PKWY
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5395
Practice Address - Country:US
Practice Address - Phone:608-276-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231472207R00000X, 207RG0300X, 207RH0002X
WI63930207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02748043Medicaid
NYRB8396 /GRP 70008AMedicare PIN
NYRB8397/GRP BA0017Medicare PIN
NY02748043Medicaid