Provider Demographics
NPI:1528159233
Name:SHAH, AJIT CHUNILAL (MD)
Entity type:Individual
Prefix:DR
First Name:AJIT
Middle Name:CHUNILAL
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 1:15651 IMPERIAL HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1600
Mailing Address - Country:US
Mailing Address - Phone:562-947-1619
Mailing Address - Fax:562-947-5969
Practice Address - Street 1:15651 IMPERIAL HWY STE 104
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1600
Practice Address - Country:US
Practice Address - Phone:562-947-1619
Practice Address - Fax:562-947-5969
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73798207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00737980Medicaid
H57331Medicare ID - Type Unspecified
CA00737980Medicaid