Provider Demographics
NPI:1851531768
Name:SHAH, AMISH KISHOR (DO, MP,H,)
Entity Type:Individual
Prefix:
First Name:AMISH
Middle Name:KISHOR
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO, MP,H,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17542 17TH ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1959
Mailing Address - Country:US
Mailing Address - Phone:714-734-5500
Mailing Address - Fax:
Practice Address - Street 1:17542 17TH ST
Practice Address - Street 2:SUITE 320
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1959
Practice Address - Country:US
Practice Address - Phone:714-734-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11673207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine