Provider Demographics
NPI:1104955616
Name:SHAH, PAYAL (OD)
Entity type:Individual
Prefix:DR
First Name:PAYAL
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 SILVERNAIL RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5402
Mailing Address - Country:US
Mailing Address - Phone:262-521-9383
Mailing Address - Fax:
Practice Address - Street 1:2315 SILVERNAIL RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5402
Practice Address - Country:US
Practice Address - Phone:262-521-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2934-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38620600Medicaid
WIV06077Medicare UPIN
WIU89759Medicare UPIN
WI001587780Medicare ID - Type Unspecified