Healthcare Provider Details

I. General information

NPI: 1588004600
Provider Name (Legal Business Name): RONAK JASWANT SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 07/15/2024
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST N
CONCORD NC
28025-2927
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-315-8968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2019-02665
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2019-02665
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number2019-02665
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: