Provider Demographics
NPI:1568763134
Name:SHAH, AMITKUMAR ASHOKKUMAR (RPT)
Entity Type:Individual
Prefix:
First Name:AMITKUMAR
Middle Name:ASHOKKUMAR
Last Name:SHAH
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6182 CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-844-6376
Mailing Address - Fax:810-344-9954
Practice Address - Street 1:6182 CREEKSIDE CT
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7445
Practice Address - Country:US
Practice Address - Phone:810-844-6376
Practice Address - Fax:810-344-9954
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist