Provider Demographics
NPI:1982919585
Name:SHAH, DISHA R (MD)
Entity type:Individual
Prefix:
First Name:DISHA
Middle Name:R
Last Name:SHAH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 TIDEWATER DR STE 19
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-3700
Mailing Address - Country:US
Mailing Address - Phone:757-330-0150
Mailing Address - Fax:877-487-3044
Practice Address - Street 1:7525 TIDEWATER DR STE 19
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-3700
Practice Address - Country:US
Practice Address - Phone:757-330-0150
Practice Address - Fax:877-487-3044
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL11535207Q00000X
ND12688207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12083Medicaid
TNQ005112Medicaid