MEDICARE: JAYESH B SHAH MD

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	207R00000X	Internal Medicine Physician	K1057	TX
2	2083P0011X	Undersea and Hyperbaric Medicine (Preventive Medicine) Physician	K1057	TX

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
2	00298U	OTHER	TX	PTAN

General Provider Information

NPI Number	:	1962404830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYESH B SHAH MD

Provider Business Mailing Address
First Line	:	PO BOX 780764
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78278-0764
Country	:	US
Telephone Number	:	210-289-5948
Fax Number	:	210-408-0117

Provider Business Practice Location Address
First Line	:	8811 VILLAGE DR
Second Line	:	NORTHEAST BAPTIST WOUND HEALING CENTER
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5415
Country	:	US
Telephone Number	:	210-297-2520
Fax Number	:	210-297-2539

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	02/23/2015

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Directions to “ JAYESH B SHAH MD” Practice Location

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