Provider Demographics
NPI:1760584247
Name:SHAH, MITA D (MD)
Entity Type:Individual
Prefix:
First Name:MITA
Middle Name:D
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:12932 CEDAR GLEN LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2951
Mailing Address - Country:US
Mailing Address - Phone:703-689-4933
Mailing Address - Fax:703-689-3849
Practice Address - Street 1:10875 MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4732
Practice Address - Country:US
Practice Address - Phone:703-352-4121
Practice Address - Fax:703-352-4122
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
VA0101232722207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology