Healthcare Provider Details

I. General information

NPI: 1942629423
Provider Name (Legal Business Name): UDAYAN KANDARP SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 09/05/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 N COURT ST STE B
VISALIA CA
93291-4920
US

IV. Provider business mailing address

6569 N RIVERSIDE DR # 102504
FRESNO CA
93722-9318
US

V. Phone/Fax

Practice location:
  • Phone: 559-625-9100
  • Fax: 559-625-9103
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA142144
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: