Healthcare Provider Details

I. General information

NPI: 1689604035
Provider Name (Legal Business Name): SANJAY SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 WALTER REED RD
FAYETTEVILLE NC
28304-4440
US

IV. Provider business mailing address

ATTN. MANAGED CARE PLANNING PO BOX 40908
FAYETTEVILLE NC
28309
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1671
  • Fax: 910-323-9656
Mailing address:
  • Phone: 910-615-6949
  • Fax: 910-615-9761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License Number9801484
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number9801484
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9801484
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: