Provider Demographics
NPI:1316915465
Name:SHAH, PRAMODCHANDRA C (MD)
Entity type:Individual
Prefix:
First Name:PRAMODCHANDRA
Middle Name:C
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 1:29 BLUE JAY RD
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940
Mailing Address - Country:US
Mailing Address - Phone:781-581-5038
Mailing Address - Fax:
Practice Address - Street 1:365 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152
Practice Address - Country:US
Practice Address - Phone:617-846-5352
Practice Address - Fax:617-846-1062
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34904208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2008912Medicaid
B72553Medicare UPIN
MA2008912Medicaid