Provider Demographics
NPI:1902868433
Name:SHAH, RAKESH R (MD)
Entity Type:Individual
Prefix:
First Name:RAKESH
Middle Name:R
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 N 1ST ST STE 250
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6132
Practice Address - Country:US
Practice Address - Phone:208-381-9384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ23212085R0202X
IDMC-15232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100155790AMedicaid
TX103357301Medicaid
123729100OtherFIRSTCARE
TX82R448OtherBLUE CROSS
TXMDJ2321OtherWORKERS COMPENSATION
NMQ3953Medicaid
300076407Medicare ID - Type UnspecifiedRAILROAD MEDICARE
123729100OtherFIRSTCARE
TXMDJ2321OtherWORKERS COMPENSATION
TX82R448Medicare ID - Type Unspecified