Provider Demographics
NPI:1639103484
Name:SHAH, MANJULA A (MD)
Entity Type:Individual
Prefix:
First Name:MANJULA
Middle Name:A
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22011 S WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3060
Mailing Address - Country:US
Mailing Address - Phone:216-491-9390
Mailing Address - Fax:
Practice Address - Street 1:3690 ORANGE PL STE 220
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4465
Practice Address - Country:US
Practice Address - Phone:216-831-1494
Practice Address - Fax:216-831-9931
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35035097S2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0281476Medicaid
E83599Medicare UPIN
SH0581513Medicare ID - Type Unspecified