Provider Demographics
NPI:1760656706
Name:SHAH, GAURANG SURENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:GAURANG
Middle Name:SURENDRA
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 1:10700 HAWTHORN TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-8767
Mailing Address - Country:US
Mailing Address - Phone:651-815-0314
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-326-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51638207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine