Provider Demographics
NPI:1518959758
Name:SHAH, PANKAJKUMAR GOPALDAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PANKAJKUMAR
Middle Name:GOPALDAS
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 1:1506 E GRIFFIN PKWY
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572
Mailing Address - Country:US
Mailing Address - Phone:956-583-0202
Mailing Address - Fax:956-583-0200
Practice Address - Street 1:1506 E GRIFFIN PKWY
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572
Practice Address - Country:US
Practice Address - Phone:956-583-0202
Practice Address - Fax:956-583-0200
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2023-06-30
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
TXJ9336207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133210809Medicaid
TX133210806Medicaid
TX00001IMedicare PIN
TX133210806Medicaid