Healthcare Provider Details

I. General information

NPI: 1508421488
Provider Name (Legal Business Name): SMIT PRAFULCHANDRA SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

2533C SIDNEY ST
PITTSBURGH PA
15203-2198
US

V. Phone/Fax

Practice location:
  • Phone: 856-649-2994
  • Fax:
Mailing address:
  • Phone: 856-649-2994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberLL84510
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number76419
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: