Provider Demographics
NPI:1639113012
Name:SHAH, MRUGESHKUMAR KANAIYALAL (MD)
Entity Type:Individual
Prefix:
First Name:MRUGESHKUMAR
Middle Name:KANAIYALAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3420 FORESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082
Mailing Address - Country:US
Mailing Address - Phone:972-278-7772
Mailing Address - Fax:469-429-1052
Practice Address - Street 1:6957 W PLANO PKWY
Practice Address - Street 2:SUITE 2600
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-1620
Practice Address - Country:US
Practice Address - Phone:972-499-4266
Practice Address - Fax:972-591-4605
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL61742081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00443ZMedicare ID - Type UnspecifiedGROUP NUMBER
TXH89824Medicare UPIN
TX8F1074Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER