Healthcare Provider Details

I. General information

NPI: 1073889002
Provider Name (Legal Business Name): NIKITA MUKESH SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HAALAND DR STE 101
THOUSAND OAKS CA
91361-5230
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-2949
  • Fax:
Mailing address:
  • Phone:
  • Fax: 972-234-0813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR7322
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301112575
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA170065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: