Basic Information
| Provider Information | |||||||||
| NPI: | 1992004642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | KSHITIJ | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014009 | ||||||||
| FaxNumber: | 5129013909 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014009 | ||||||||
| FaxNumber: | 5129013909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA09601100 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | Q4280 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | Q4280 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 276756 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 362544401 | 05 | TX | MEDICAID |