Provider Demographics
NPI:1689649527
Name:SHAH, IBRAHIM (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
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 1:2134 HAMPTON PL
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3691
Mailing Address - Country:US
Mailing Address - Phone:517-347-3000
Mailing Address - Fax:517-347-8393
Practice Address - Street 1:2134 HAMPTON PL
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3691
Practice Address - Country:US
Practice Address - Phone:517-347-3000
Practice Address - Fax:517-347-8393
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078328207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1689649527Medicaid
MI0P27070013Medicare PIN