Provider Demographics
NPI:1831143676
Name:SHAH, GAUTAM MOTLLAL (MD)
Entity Type:Individual
Prefix:
First Name:GAUTAM
Middle Name:MOTLLAL
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 1:10192 W. COGGINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3405
Mailing Address - Country:US
Mailing Address - Phone:623-974-2434
Mailing Address - Fax:623-974-4925
Practice Address - Street 1:10192 W. COGGINS DRIVE
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3405
Practice Address - Country:US
Practice Address - Phone:623-974-2434
Practice Address - Fax:623-974-4925
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10116207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ208745Medicaid
AZ208745Medicaid
Z71514Medicare PIN