Healthcare Provider Details

I. General information

NPI: 1770112435
Provider Name (Legal Business Name): HEEMA KUMUD SHAH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 06/15/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E BUTLER RD
GREENVILLE SC
29607-5910
US

IV. Provider business mailing address

1202 E BUTLER RD
GREENVILLE SC
29607-5910
US

V. Phone/Fax

Practice location:
  • Phone: 864-627-3800
  • Fax: 864-672-2654
Mailing address:
  • Phone: 864-627-3800
  • Fax: 864-672-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5115
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number93608
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: