Provider Demographics
NPI:1629244652
Name:SHAH, KETAN K (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:K
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1250
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4633
Mailing Address - Country:US
Mailing Address - Phone:949-744-5441
Mailing Address - Fax:949-266-1661
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1250
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4633
Practice Address - Country:US
Practice Address - Phone:949-744-5441
Practice Address - Fax:949-266-1661
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120437207R00000X, 207RG0100X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics