Healthcare Provider Details

I. General information

NPI: 1124693932
Provider Name (Legal Business Name): KAUSHAL SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E MAIN ST
NORMAN OK
73071-5305
US

IV. Provider business mailing address

PO BOX 151
NORMAN OK
73070-0151
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-6602
  • Fax: 405-573-6684
Mailing address:
  • Phone: 405-573-6602
  • Fax: 405-573-6684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number38334
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: