Healthcare Provider Details

I. General information

NPI: 1477972198
Provider Name (Legal Business Name): ANDRITA SHAH D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD STE 450
DETROIT MI
48202-3026
US

IV. Provider business mailing address

5801 ALLENTOWN RD STE 202
CAMP SPRINGS MD
20746-4562
US

V. Phone/Fax

Practice location:
  • Phone: 313-871-3751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH84394
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: