Healthcare Provider Details

I. General information

NPI: 1023019882
Provider Name (Legal Business Name): RAJU S SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

5705 MONCLOVA RD SUITE 203
MAUMEE OH
43537-1875
US

IV. Provider business mailing address

5705 MONCLOVA RD SUITE 203
MAUMEE OH
43537-1875
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-2622
  • Fax:
Mailing address:
  • Phone: 419-893-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number35-03-6372-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: