Healthcare Provider Details

I. General information

NPI: 1811421597
Provider Name (Legal Business Name): SARDAR MOMIN SHAH-KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 STANAFORD RD
BECKLEY WV
25801-3140
US

IV. Provider business mailing address

250 STANAFORD RD
BECKLEY WV
25801-3140
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-2820
  • Fax: 304-254-2821
Mailing address:
  • Phone: 304-254-2820
  • Fax: 304-254-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number29185
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01096486A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0097816
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberE-16780
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA11750800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: