Provider Demographics
NPI:1609938505
Name:MEDICAL PRACTICE, LTD.
Entity Type:Organization
Organization Name:MEDICAL PRACTICE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DHARMESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-543-6861
Mailing Address - Street 1:710 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23324-2637
Mailing Address - Country:US
Mailing Address - Phone:757-543-6861
Mailing Address - Fax:757-543-4082
Practice Address - Street 1:710 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-2637
Practice Address - Country:US
Practice Address - Phone:757-543-6861
Practice Address - Fax:757-543-4082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA461191OtherANTHEM
VA5882401Medicaid
VA12090OtherOPTIMA HEALTH
VA110138225OtherMEDICARE-RAILROAD
VA461191OtherANTHEM
VAB07291Medicare UPIN
VA12090OtherOPTIMA HEALTH