Healthcare Provider Details

I. General information

NPI: 1366671265
Provider Name (Legal Business Name): DISHA SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 DUTCHMANS PKWY SUITE 175
LOUISVILLE KY
40205-3340
US

IV. Provider business mailing address

6801 DIXIE HWY SUITE 130
LOUISVILLE KY
40258-3913
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-6055
  • Fax: 502-361-6087
Mailing address:
  • Phone: 502-361-6055
  • Fax: 502-361-6087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD439334
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number46305
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: