Healthcare Provider Details

I. General information

NPI: 1134119597
Provider Name (Legal Business Name): NIRAJ SHASHIKANT SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 S MAIN ST
CLAWSON MI
48017-2061
US

IV. Provider business mailing address

PO BOX 1829
TROY MI
48099-1829
US

V. Phone/Fax

Practice location:
  • Phone: 248-588-4777
  • Fax: 248-588-1241
Mailing address:
  • Phone: 248-588-4777
  • Fax: 248-588-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberNS067271
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: