Provider Demographics
NPI:1306116116
Name:AMI P SHAH
Entity type:Organization
Organization Name:AMI P SHAH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMI
Authorized Official - Middle Name:PATEL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-478-2778
Mailing Address - Street 1:7119 ELK GROVE BLVD
Mailing Address - Street 2:STE 123
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-9568
Mailing Address - Country:US
Mailing Address - Phone:916-478-2778
Mailing Address - Fax:916-478-2779
Practice Address - Street 1:7119 ELK GROVE BLVD
Practice Address - Street 2:STE 123
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-9568
Practice Address - Country:US
Practice Address - Phone:916-478-2778
Practice Address - Fax:916-478-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH210Medicare UPIN