Provider Demographics
NPI:1629047212
Name:SHAH, ANIL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIL
Middle Name:
Last Name:SHAH
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 1:19300 SW 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7706
Mailing Address - Country:US
Mailing Address - Phone:503-692-2439
Mailing Address - Fax:
Practice Address - Street 1:19300 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7706
Practice Address - Country:US
Practice Address - Phone:503-692-2439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25450207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277891Medicaid
OR130814Medicare ID - Type Unspecified
G09755Medicare UPIN