Provider Demographics
NPI:1285871681
Name:SHAH, VANDANA MRUGESH (MD)
Entity type:Individual
Prefix:
First Name:VANDANA
Middle Name:MRUGESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VANDANA
Other - Middle Name:
Other - Last Name:PALAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2001 N JEFFERSON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-2338
Mailing Address - Country:US
Mailing Address - Phone:903-577-7003
Mailing Address - Fax:903-577-3933
Practice Address - Street 1:2001 N JEFFERSON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2338
Practice Address - Country:US
Practice Address - Phone:903-577-7003
Practice Address - Fax:903-577-3933
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
J400007945Medicare PIN