Provider Demographics
NPI:1689604035
Name:SHAH, SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
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:ATTN. MANAGED CARE PLANNING
Mailing Address - Street 2:PO BOX 40908
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309
Mailing Address - Country:US
Mailing Address - Phone:910-615-6949
Mailing Address - Fax:910-615-9761
Practice Address - Street 1:1218 WALTER REED RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4440
Practice Address - Country:US
Practice Address - Phone:910-323-1671
Practice Address - Fax:910-323-9656
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801484207LH0002X, 207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911560Medicaid
NC390007497OtherMEDICARE RAILROAD
NC8911560Medicaid
G79276Medicare UPIN
NC2262628BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER