Provider Demographics
NPI:1568504397
Name:SHAH, RIDDHI JAY (DO)
Entity Type:Individual
Prefix:
First Name:RIDDHI
Middle Name:JAY
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:3901 STONEGATE PARK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9137
Mailing Address - Country:US
Mailing Address - Phone:269-408-4265
Mailing Address - Fax:269-556-6020
Practice Address - Street 1:3901 STONEGATE PARK
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9137
Practice Address - Country:US
Practice Address - Phone:269-408-4265
Practice Address - Fax:269-556-6020
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-08-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY011440363AS0400X
MDC0003431363A00000X
MI5101020760207N00000X
OH58.004442208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1568504397Medicaid
MIMI2051Medicare PIN