1316129893 NPI number — DR. LISA C SHAH D.O.

Table of content: DR. LISA C SHAH D.O. (NPI 1316129893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316129893 NPI number — DR. LISA C SHAH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
LISA
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316129893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 PUDDLEDOCK RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PRINCE GEORGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23875-1268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-526-1111
Provider Business Mailing Address Fax Number:
804-526-2978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 PUDDLEDOCK RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PRINCE GEORGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23875-1268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-526-1111
Provider Business Practice Location Address Fax Number:
804-526-2978
Provider Enumeration Date:
11/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0102202032 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 016465P04 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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