Provider Demographics
NPI:1336176619
Name:VIVEK SHAH MD PLLC
Entity Type:Organization
Organization Name:VIVEK SHAH MD PLLC
Other - Org Name:28TH AVE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THE DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIVEK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-576-0600
Mailing Address - Street 1:2802 W NOB HILL BLVD # A
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4982
Mailing Address - Country:US
Mailing Address - Phone:509-576-0600
Mailing Address - Fax:509-576-0602
Practice Address - Street 1:2802 W NOB HILL BLVD # A
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4982
Practice Address - Country:US
Practice Address - Phone:509-576-0600
Practice Address - Fax:509-576-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care