Provider Demographics
NPI:1992016919
Name:SHAH, NEIL NAYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:NAYAN
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 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-677-2409
Mailing Address - Fax:562-741-4479
Practice Address - Street 1:512 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4619
Practice Address - Country:US
Practice Address - Phone:682-218-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA257897207R00000X
TXQ5094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354776202Medicaid
TX439779YMGJMedicare PIN
TX439779YLP1Medicare PIN