Provider Demographics
NPI:1588390140
Name:SHAH, SURAJ NIKHIL
Entity type:Individual
Prefix:
First Name:SURAJ
Middle Name:NIKHIL
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35948 CARNATION WAY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-2638
Mailing Address - Country:US
Mailing Address - Phone:510-453-0273
Mailing Address - Fax:
Practice Address - Street 1:39111 PASEO PADRE PKWY STE 109
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1615
Practice Address - Country:US
Practice Address - Phone:510-453-0273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist