Provider Demographics
NPI:1396137865
Name:SHAH, SANKET (MD)
Entity type:Individual
Prefix:
First Name:SANKET
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 1:1360 E HERNDON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3326
Mailing Address - Country:US
Mailing Address - Phone:594-495-0505
Mailing Address - Fax:559-432-2632
Practice Address - Street 1:1360 E HERNDON AVE STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3326
Practice Address - Country:US
Practice Address - Phone:559-449-5050
Practice Address - Fax:559-432-2632
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY54051207W00000X, 207W00000X
CAA185699207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100676570Medicaid