Provider Demographics
NPI:1396763827
Name:SHAH, MUKHTAR H (MD)
Entity type:Individual
Prefix:DR
First Name:MUKHTAR
Middle Name:H
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 1:1148 S HILLSIDE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-4006
Mailing Address - Country:US
Mailing Address - Phone:316-687-0006
Mailing Address - Fax:316-687-0328
Practice Address - Street 1:1148 S. HILLSIDE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-4006
Practice Address - Country:US
Practice Address - Phone:316-687-0006
Practice Address - Fax:316-687-0328
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-173522084P0800X
KS04173522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS047770OtherBLUE CROSS BLUE SHIELD
KS260029156OtherRR MEDICARE
KS100089090EMedicaid
B69419Medicare UPIN
KS100089090EMedicaid