Provider Demographics
NPI:1215162318
Name:SHAH, JAY AJIT (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:AJIT
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29345 SW TOWN CENTER LOOP E STE 110
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070
Practice Address - Country:US
Practice Address - Phone:503-582-2100
Practice Address - Fax:503-582-2101
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD166559207Q00000X, 207Q00000X
VA0101247091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673576Medicaid
VAC06778OtherGROUP PTAN
VAC09633OtherGROUP PTAN
VAC09633OtherGROUP PTAN