Provider Demographics
NPI:1699790436
Name:SHAH, ANISH P (MD)
Entity type:Individual
Prefix:
First Name:ANISH
Middle Name:P
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 1:14085 CROWN CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1458
Mailing Address - Country:US
Mailing Address - Phone:703-763-5224
Mailing Address - Fax:703-763-5374
Practice Address - Street 1:14085 CROWN CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1458
Practice Address - Country:US
Practice Address - Phone:703-763-5224
Practice Address - Fax:703-763-5374
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061027207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC03010002OtherCARE FIRST BCBS
DC038049200Medicaid
MDP00376508OtherRR MEDICARE
DCP00422892OtherRRMCR DC
MD410276200Medicaid
MD89511901OtherCARE FIRST BCBS
MDG02225V01Medicare PIN
MDP00376508OtherRR MEDICARE
DC03010002OtherCARE FIRST BCBS