Healthcare Provider Details

I. General information

NPI: 1649546995
Provider Name (Legal Business Name): MITESH V SHAH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8926 WOODYARD RD STE 602
CLINTON MD
20735-4235
US

IV. Provider business mailing address

8926 WOODYARD RD STE 602
CLINTON MD
20735-4235
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-9414
  • Fax: 301-868-6055
Mailing address:
  • Phone: 301-868-9414
  • Fax: 301-868-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0102204859
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberH0083175
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: