Provider Demographics
NPI:1336226646
Name:SHAH, CARLA JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:JEAN
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:JEAN
Other - Last Name:MUNTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10945 N PORT WASHINGTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5078
Mailing Address - Country:US
Mailing Address - Phone:262-292-3151
Mailing Address - Fax:
Practice Address - Street 1:10945 N PORT WASHINGTON RD STE 201
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5078
Practice Address - Country:US
Practice Address - Phone:262-292-3151
Practice Address - Fax:414-434-0467
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50269-0202085R0202X
WAMD605072122085R0202X
WI1774-8502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100008748Medicaid
WA2042683Medicaid
WI680861159Medicare PIN
WI1336226646Medicaid