Healthcare Provider Details

I. General information

NPI: 1902194848
Provider Name (Legal Business Name): MITESH SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE BLDG 280
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

100 E LANCASTER AVE BLDG 280
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 610-642-3005
  • Fax: 610-649-4367
Mailing address:
  • Phone: 610-642-3005
  • Fax: 610-649-4367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD458198
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: