Provider Demographics
NPI:1992004642
Name:SHAH, KSHITIJ (MD)
Entity Type:Individual
Prefix:
First Name:KSHITIJ
Middle Name:
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 1:12221 N MOPAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2401
Mailing Address - Country:US
Mailing Address - Phone:512-901-4009
Mailing Address - Fax:512-901-3909
Practice Address - Street 1:12221 N MOPAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2401
Practice Address - Country:US
Practice Address - Phone:512-901-4009
Practice Address - Fax:512-901-3909
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09601100207R00000X
TXQ4280208M00000X, 207R00000X
NY276756207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362544401Medicaid
TX362544401Medicaid