Provider Demographics
NPI:1740506351
Name:SHAH, MIRA MAHENDRA (MD)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:MAHENDRA
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2689
Mailing Address - Country:US
Mailing Address - Phone:313-399-7668
Mailing Address - Fax:313-916-3264
Practice Address - Street 1:2799 W GRAND BLVD # M2
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-1021
Practice Address - Fax:313-916-3264
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010966852085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology