Provider Demographics
NPI:1700236973
Name:SHAH, PRATIK (DO)
Entity Type:Individual
Prefix:DR
First Name:PRATIK
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10636 WILSHIRE BLVD APT 504
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-7306
Mailing Address - Country:US
Mailing Address - Phone:847-571-3866
Mailing Address - Fax:
Practice Address - Street 1:1011 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5806
Practice Address - Country:US
Practice Address - Phone:626-851-6484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024600207P00000X
OH34.014355207P00000X
CA20A18674207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine