Provider Demographics
NPI:1578563516
Name:CHOWDHURY, SHAH ALAM (MD)
Entity Type:Individual
Prefix:
First Name:SHAH
Middle Name:ALAM
Last Name:CHOWDHURY
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5384
Practice Address - Street 1:2490 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2122
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-5384
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049484A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200290410Medicaid