Provider Demographics
NPI:1972521086
Name:SHAH, ANIL R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIL
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 1:757 45TH AVE
Mailing Address - Street 2:STE. 201
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2911
Mailing Address - Country:US
Mailing Address - Phone:219-934-2461
Mailing Address - Fax:219-934-2478
Practice Address - Street 1:9800 VALPARAISO DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4040
Practice Address - Country:US
Practice Address - Phone:219-934-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235640207Y00000X
IL036120006207YS0123X
IN01066901A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200948380Medicaid
NY235640OtherNYS LICENSE#