Provider Demographics
NPI:1194810184
Name:SHAH, MODASER - (MD)
Entity type:Individual
Prefix:DR
First Name:MODASER
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 1:530 E 34TH ST.
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-347-7540
Mailing Address - Fax:417-347-7549
Practice Address - Street 1:530 E 34TH ST.
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64803-2526
Practice Address - Country:US
Practice Address - Phone:417-347-7540
Practice Address - Fax:417-347-7549
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR71702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBCBS10290A005OtherBCBS
B18419Medicare UPIN