Provider Demographics
NPI:1568449395
Name:SHAH, TUSHAR R (MD)
Entity Type:Individual
Prefix:
First Name:TUSHAR
Middle Name:R
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 1:302 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2044
Mailing Address - Country:US
Mailing Address - Phone:810-762-8490
Mailing Address - Fax:810-762-3735
Practice Address - Street 1:302 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2044
Practice Address - Country:US
Practice Address - Phone:810-762-8490
Practice Address - Fax:810-762-3735
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010739282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00100938OtherRR MEDICARE
MI4538999Medicaid
MI0G36043Medicare ID - Type Unspecified
MIH93451Medicare UPIN