Provider Demographics
NPI:1831502095
Name:SHAH, VIJAL (OD)
Entity Type:Individual
Prefix:DR
First Name:VIJAL
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11139 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5004
Mailing Address - Country:US
Mailing Address - Phone:703-679-1030
Mailing Address - Fax:
Practice Address - Street 1:11139 LEE HWY
Practice Address - Street 2:STORE # 5780
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5004
Practice Address - Country:US
Practice Address - Phone:703-679-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist