Provider Demographics
NPI:1316122724
Name:SHIMUL Y SHAH
Entity type:Organization
Organization Name:SHIMUL Y SHAH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIMUL
Authorized Official - Middle Name:Y
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-642-1300
Mailing Address - Street 1:122 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1106
Mailing Address - Country:US
Mailing Address - Phone:937-642-1300
Mailing Address - Fax:937-642-0101
Practice Address - Street 1:122 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1106
Practice Address - Country:US
Practice Address - Phone:937-642-1300
Practice Address - Fax:937-642-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5091261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1043254170OtherINDIVIDUAL NPI
OH2636099Medicaid
OH2636099Medicaid