Provider Demographics
NPI:1740226505
Name:SHAH, SANJAYKUMAR B (MD)
Entity Type:Individual
Prefix:
First Name:SANJAYKUMAR
Middle Name:B
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 1:2300 HOSPITAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2394
Mailing Address - Country:US
Mailing Address - Phone:318-212-7830
Mailing Address - Fax:318-212-7835
Practice Address - Street 1:2300 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2394
Practice Address - Country:US
Practice Address - Phone:318-212-7830
Practice Address - Fax:318-212-7835
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11384R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1661104Medicaid
LA5W323DE91Medicare PIN
LA5W323C731Medicare PIN
LA1661104Medicaid
LA5W323CT31Medicare PIN
LA5W323Medicare PIN
LA5W323CT19Medicare PIN
LA5W323C858Medicare PIN