Provider Demographics
NPI:1558415950
Name:SHAH, LEENA GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:LEENA
Middle Name:GAUTAM
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 1:40 HART ST
Mailing Address - Street 2:BUILDING A
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1743
Mailing Address - Country:US
Mailing Address - Phone:860-832-8609
Mailing Address - Fax:860-832-8613
Practice Address - Street 1:40 HART ST
Practice Address - Street 2:BUILDING A
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1743
Practice Address - Country:US
Practice Address - Phone:860-832-8609
Practice Address - Fax:860-832-8613
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028603207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001286039Medicaid
CT001286039Medicaid