Provider Demographics
NPI:1255521332
Name:SHAH, REHAN (MD)
Entity type:Individual
Prefix:
First Name:REHAN
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:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-0516
Mailing Address - Country:US
Mailing Address - Phone:214-272-2774
Mailing Address - Fax:
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 203
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6286
Practice Address - Country:US
Practice Address - Phone:904-330-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071567207R00000X, 207RN0300X
WAMD61072096207RN0300X
TXS2503207RN0300X
390200000X
FLME127447207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2173910Medicaid