Healthcare Provider Details

I. General information

NPI: 1497940159
Provider Name (Legal Business Name): NISHANT SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 12/02/2023
Certification Date: 12/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N HOWARD ST
BALTIMORE MD
21201-3610
US

IV. Provider business mailing address

19 S COLLINGTON AVE
BALTIMORE MD
21231-2013
US

V. Phone/Fax

Practice location:
  • Phone: 410-576-1414
  • Fax: 410-385-2762
Mailing address:
  • Phone: 925-863-9621
  • Fax: 347-763-8386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD79853
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberD79853
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: