Basic Information
| Provider Information | |||||||||
| NPI: | 1730155896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | MEHUL | ||||||||
| MiddleName: | JITENDRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 616 | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201460616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 224A CORNWALL ST NW | ||||||||
| Address2: | LOUDOUN COMMUNITY HEALTH CENTER | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432120 | ||||||||
| FaxNumber: | 7034432033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 01/21/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 0103300893 | VA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0000X | 0103300893 | VA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Sports Medicine | 213ES0131X | 0103300893 | VA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | J4630001 | 01 | VA | CAREFIRST BC/BS | OTHER | 1841465291 | 01 | VA | GROUP NPI | OTHER | 350392 | 01 | VA | ANTHEM BC/BS | OTHER | 3854800 | 01 | VA | CIGNA | OTHER | 7980784 | 01 | VA | AETNA | OTHER |