Provider Demographics
NPI:1649332412
Name:SHAH, KAMLESH S (MD)
Entity type:Individual
Prefix:
First Name:KAMLESH
Middle Name:S
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 1:2222 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:307-577-5222
Mailing Address - Fax:307-577-5225
Practice Address - Street 1:2222 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609
Practice Address - Country:US
Practice Address - Phone:307-577-5222
Practice Address - Fax:307-577-5225
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5881A207K00000X
CO38777207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY111801300Medicaid
F71940Medicare UPIN
WYW9585Medicare ID - Type Unspecified