Healthcare Provider Details

I. General information

NPI: 1902803513
Provider Name (Legal Business Name): PRAKASH SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 KENTON ST STE 1D
HOPKINSVILLE KY
42240-1981
US

IV. Provider business mailing address

1724 KENTON ST STE 1D
HOPKINSVILLE KY
42240-1981
US

V. Phone/Fax

Practice location:
  • Phone: 270-887-9066
  • Fax: 270-887-9199
Mailing address:
  • Phone: 270-887-9066
  • Fax: 270-887-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31011
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: