Healthcare Provider Details

I. General information

NPI: 1104894864
Provider Name (Legal Business Name): MAYANK KANTILAL SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 BARKS RD W
MARION OH
43302-7367
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 740-383-7980
  • Fax: 740-383-3040
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-063565
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: