Provider Demographics
NPI:1679525125
Name:HARIDAS, SHOBHA (MD)
Entity Type:Individual
Prefix:
First Name:SHOBHA
Middle Name:
Last Name:HARIDAS
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:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-430-2230
Mailing Address - Fax:606-237-2526
Practice Address - Street 1:285 SOUTHSIDE MALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSON
Practice Address - State:KY
Practice Address - Zip Code:41503-3905
Practice Address - Country:US
Practice Address - Phone:606-430-2226
Practice Address - Fax:606-237-7530
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19739208000000X
KY39430208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64943178Medicaid
WV6700091000Medicaid
WV6700091000Medicaid
WVH09136Medicare UPIN