Provider Demographics
NPI:1306956297
Name:SHAH, MANOJ P (MD)
Entity type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:P
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 1:14055 SEAWAY RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-868-5555
Mailing Address - Fax:228-574-2002
Practice Address - Street 1:14055 SEAWAY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-868-5555
Practice Address - Fax:228-574-2002
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17037207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123304Medicaid
MS060000486Medicare ID - Type Unspecified
MS00123304Medicaid