Healthcare Provider Details

I. General information

NPI: 1134450737
Provider Name (Legal Business Name): JAY SHAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 INDIAN BOUNDARY RD
CHESTERTON IN
46304-1695
US

IV. Provider business mailing address

10855 VIRGINIA ST
CROWN POINT IN
46307-0210
US

V. Phone/Fax

Practice location:
  • Phone: 872-317-0501
  • Fax: 872-317-0500
Mailing address:
  • Phone: 872-317-0501
  • Fax: 872-317-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125052454
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01072775A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: