Basic Information
| Provider Information | |||||||||
| NPI: | 1174747059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | VIPUL | ||||||||
| MiddleName: | CHANDRAHAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1632 E ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281124017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953725 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME101111 | FL | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 2013-01062 | NC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 000569500 | 05 | FL | MEDICAID |