Provider Demographics
NPI:1720360282
Name:SHAH, JINAL DEEPAK (PT)
Entity Type:Individual
Prefix:
First Name:JINAL
Middle Name:DEEPAK
Last Name:SHAH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 BARG DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6913
Mailing Address - Country:US
Mailing Address - Phone:586-819-6989
Mailing Address - Fax:
Practice Address - Street 1:6041 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-4501
Practice Address - Country:US
Practice Address - Phone:586-264-4343
Practice Address - Fax:586-264-0539
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist