Provider Demographics
NPI:1932126497
Name:SHAH, INDRAVADAN SOMALAL (MD)
Entity Type:Individual
Prefix:DR
First Name:INDRAVADAN
Middle Name:SOMALAL
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 1:931 BUENA VISTA STREET
Mailing Address - Street 2:#504
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010
Mailing Address - Country:US
Mailing Address - Phone:626-358-2576
Mailing Address - Fax:626-358-2287
Practice Address - Street 1:931 BUENA VISTA STREET
Practice Address - Street 2:#504
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:626-358-2576
Practice Address - Fax:626-358-2287
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A317810Medicaid
A26600Medicare UPIN
CAA26600Medicare ID - Type Unspecified