Provider Demographics
NPI:1124693932
Name:SHAH, KAUSHAL (MD)
Entity type:Individual
Prefix:
First Name:KAUSHAL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-0151
Mailing Address - Country:US
Mailing Address - Phone:405-573-6602
Mailing Address - Fax:405-573-6684
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-573-6602
Practice Address - Fax:405-573-6684
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38334390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program