Provider Demographics
NPI:1568479327
Name:SHAH, KHALIQ A (MD)
Entity type:Individual
Prefix:
First Name:KHALIQ
Middle Name:A
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 1:1825 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 13
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-7301
Mailing Address - Country:US
Mailing Address - Phone:408-236-3540
Mailing Address - Fax:408-236-3545
Practice Address - Street 1:1825 CIVIC CENTER DR
Practice Address - Street 2:SUITE 13
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-7301
Practice Address - Country:US
Practice Address - Phone:408-236-3540
Practice Address - Fax:408-236-3545
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81463207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37293Medicare UPIN