Provider Demographics
NPI:1952315988
Name:SHAH, SANJAY JAYANTILAL (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:JAYANTILAL
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 1:5523 W LARIAT LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-1231
Mailing Address - Country:US
Mailing Address - Phone:602-842-7555
Mailing Address - Fax:602-743-0183
Practice Address - Street 1:5523 W LARIAT LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-1231
Practice Address - Country:US
Practice Address - Phone:602-842-7555
Practice Address - Fax:602-743-0183
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD23307207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G16175Medicare UPIN