1366671265 NPI number — DISHA SHAH MD

Table of content: DISHA SHAH MD (NPI 1366671265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366671265 NPI number — DISHA SHAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
DISHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1366671265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6801 DIXIE HWY
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40258-3913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-361-6055
Provider Business Mailing Address Fax Number:
502-361-6087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6400 DUTCHMANS PKWY
Provider Second Line Business Practice Location Address:
SUITE 175
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40205-3340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-6055
Provider Business Practice Location Address Fax Number:
502-361-6087
Provider Enumeration Date:
07/13/2009

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: 2084N0600X , with the licence number:  MD439334 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0600X , with the licence number: 46305 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100250160 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01253581 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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