Basic Information
| Provider Information | |||||||||
| NPI: | 1174500664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | PRIYAMVADA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAH | ||||||||
| OtherFirstName: | PRIYA | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8911 LIBERTY MILLS RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468046311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739465 | ||||||||
| FaxNumber: | 2602669406 | ||||||||
| Practice Location | |||||||||
| Address1: | 8911 LIBERTY MILLS RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468046311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739465 | ||||||||
| FaxNumber: | 2602669406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01029161A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000111784 | 01 | ANTHEM | OTHER | 0000002003211 | 01 | IN | ANTHEM | OTHER | 100051620 | 05 | IN | MEDICAID | 1845 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 3937240003 | 01 | IN | MEDICARE DMEPOS | OTHER | 4052315 | 01 | AETNA | OTHER | 080130031 | 01 | RAILROAD MEDICARE | OTHER |