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General NPI Number Information
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NPI Number | 1265865034
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Entity Type | Individual
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Provider Name | GAUTAM VINOD SHAH M.D
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Gender | Male
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Dates
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Enumeration Date | 08/15/2013
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Last Update Date | 07/12/2019
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Provider Practice Location Address
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Address Line | 20455 LORAIN RD FL 2
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City | FAIRVIEW PARK
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State | OH
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Zip | 44126
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Country | US
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Telephone | 216-408-1044
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Fax |
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Provider Business Mailing Address
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Address Line | 20455 LORAIN RD FL 2
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City | FAIRVIEW PARK
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State | OH
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Zip | 44126-3530
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Country | US
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Telephone | 216-408-1044
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 35.136566
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License Number State | OH
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