Provider Demographics
NPI:1205360203
Name:JAYDEEP S. SHAH, M.D. PLLC
Entity type:Organization
Organization Name:JAYDEEP S. SHAH, M.D. PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-387-7693
Mailing Address - Street 1:602 BENTLEY MNR
Mailing Address - Street 2:
Mailing Address - City:SHAVANO PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2079
Mailing Address - Country:US
Mailing Address - Phone:210-387-7693
Mailing Address - Fax:210-481-3793
Practice Address - Street 1:602 BENTLEY MNR
Practice Address - Street 2:
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78249-2079
Practice Address - Country:US
Practice Address - Phone:210-387-7693
Practice Address - Fax:210-481-3793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0930207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046693002Medicaid