Provider Demographics
NPI:1821594698
Name:SHAH, JANITRA VENKATESAN (MD)
Entity Type:Individual
Prefix:
First Name:JANITRA
Middle Name:VENKATESAN
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANITRA
Other - Middle Name:
Other - Last Name:VENKATESAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1801 ROZZELLES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4228
Mailing Address - Country:US
Mailing Address - Phone:704-446-9987
Mailing Address - Fax:
Practice Address - Street 1:1801 ROZZELLES FERRY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-4228
Practice Address - Country:US
Practice Address - Phone:704-446-9987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11154100207Q00000X
390200000X
NC2024-00426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program