Healthcare Provider Details

I. General information

NPI: 1124156906
Provider Name (Legal Business Name): MADHURI SHAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S 400 E
SALT LAKE CITY UT
84111-3501
US

IV. Provider business mailing address

515 SO 400 E
SALT LAKE CITY UT
84111-3501
US

V. Phone/Fax

Practice location:
  • Phone: 801-363-3616
  • Fax: 801-363-9051
Mailing address:
  • Phone: 801-363-3616
  • Fax: 801-363-9051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number164193-1203
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: