Provider Demographics
NPI:1598285884
Name:VALJI, SHAAN (MD)
Entity Type:Individual
Prefix:
First Name:SHAAN
Middle Name:
Last Name:VALJI
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 1:130 INDEPENDENCE LN
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-3073
Mailing Address - Country:US
Mailing Address - Phone:423-562-1705
Mailing Address - Fax:423-566-3718
Practice Address - Street 1:130 INDEPENDENCE LN
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3073
Practice Address - Country:US
Practice Address - Phone:423-562-1705
Practice Address - Fax:423-566-3718
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125070183207Q00000X
IL125-070183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ061012Medicaid