Healthcare Provider Details

I. General information

NPI: 1376004895
Provider Name (Legal Business Name): CRYSTAL R. SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

IV. Provider business mailing address

3500 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4395
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2164
  • Fax:
Mailing address:
  • Phone: 215-590-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD481600
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: