Provider Demographics
NPI:1962705004
Name:SHAH, ROSHNI MUKESH (DO)
Entity type:Individual
Prefix:DR
First Name:ROSHNI
Middle Name:MUKESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ROSHNI
Other - Middle Name:SHAH
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:22250 PROVIDENCE DR STE 705
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6215
Mailing Address - Country:US
Mailing Address - Phone:248-552-9858
Mailing Address - Fax:248-552-9510
Practice Address - Street 1:22250 PROVIDENCE DR STE 705
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6215
Practice Address - Country:US
Practice Address - Phone:248-552-9858
Practice Address - Fax:248-552-9510
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019730207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962705004Medicaid
MI0B510740OtherBCBS
MI1962705004Medicaid