Healthcare Provider Details

I. General information

NPI: 1356921704
Provider Name (Legal Business Name): DEEPAK KUMAR SHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2021
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 MYRTLE ST STE 120
ERIE PA
16502-4602
US

IV. Provider business mailing address

2314 SASSAFRAS ST STE 2
ERIE PA
16502-2721
US

V. Phone/Fax

Practice location:
  • Phone: 814-456-9197
  • Fax: 814-455-2765
Mailing address:
  • Phone: 412-325-5808
  • Fax: 814-452-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD496655
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: