Provider Demographics
NPI:1629517321
Name:SHAH, KETUL (DPT)
Entity Type:Individual
Prefix:
First Name:KETUL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 SE 16TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3819
Mailing Address - Country:US
Mailing Address - Phone:239-772-2363
Mailing Address - Fax:239-772-2365
Practice Address - Street 1:2530 BOBCAT VILLAGE CENTER RD UNIT C
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288
Practice Address - Country:US
Practice Address - Phone:941-426-7400
Practice Address - Fax:941-426-7400
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist