Provider Demographics
NPI:1922180694
Name:SHAH, GAURANG B (MD)
Entity Type:Individual
Prefix:
First Name:GAURANG
Middle Name:B
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 1:2025 CORPORATE DR.
Mailing Address - Street 2:STE 1
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8884
Mailing Address - Country:US
Mailing Address - Phone:859-625-0045
Mailing Address - Fax:859-624-0076
Practice Address - Street 1:2025 CORPORATE DR
Practice Address - Street 2:STE 1
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8884
Practice Address - Country:US
Practice Address - Phone:859-625-0045
Practice Address - Fax:859-624-0076
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32532207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64325327Medicaid
KY64325327Medicaid
KY7974Medicare ID - Type Unspecified