Basic Information
| Provider Information | |||||||||
| NPI: | 1154362770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SANDEEP | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 410108 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641410108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056076699 | ||||||||
| FaxNumber: | 4056076685 | ||||||||
| Practice Location | |||||||||
| Address1: | 1851 S KELLY AVE STE A | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056076699 | ||||||||
| FaxNumber: | 4056076685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | 22912 | OK | Y | 207W00000X | 22912 | OK | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200198330A | 05 | OK | MEDICAID |