MEDICARE: BOBBY AJAY SHAH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0204X	Vascular & Interventional Radiology Physician	01056041A	IN
2	2085R0202X	Diagnostic Radiology Physician	01056041A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	300135676	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871534925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOBBY AJAY SHAH M.D.

Provider Business Mailing Address
First Line	:	825 E LINCOLNWAY
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-5803
Country	:	US
Telephone Number	:	219-464-4891
Fax Number	:	219-464-1873

Provider Business Practice Location Address
First Line	:	3275 SW DARWIN BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-3317
Country	:	US
Telephone Number	:	800-437-2672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	01/16/2023

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Directions to “ BOBBY AJAY SHAH M.D.” Practice Location

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