Healthcare Provider Details

I. General information

NPI: 1013086446
Provider Name (Legal Business Name): MUKUND SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 HOLLYWOOD RD SUITE 102
SAINT JOSEPH MI
49085-8510
US

IV. Provider business mailing address

3800 HOLLYWOOD RD SUITE 102
SAINT JOSEPH MI
49085-8510
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-2727
  • Fax: 269-428-0377
Mailing address:
  • Phone: 269-428-2727
  • Fax: 269-428-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301039964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: