Provider Demographics
NPI:1710449764
Name:SHAH, KISHAN MITESH (MD)
Entity Type:Individual
Prefix:DR
First Name:KISHAN
Middle Name:MITESH
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 1:1633 N CAPTIAL AVENUE
Mailing Address - Street 2:MT SUITE 640
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-962-8881
Mailing Address - Fax:317-962-0838
Practice Address - Street 1:1633 N CAPTIAL AVENUE
Practice Address - Street 2:MT SUITE 640
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-962-8881
Practice Address - Fax:317-962-0838
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program