Provider Demographics
NPI:1902803513
Name:SHAH, PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 KENTON ST
Mailing Address - Street 2:STE 1D
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1981
Mailing Address - Country:US
Mailing Address - Phone:270-887-9066
Mailing Address - Fax:270-887-9199
Practice Address - Street 1:1724 KENTON ST
Practice Address - Street 2:STE 1D
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1981
Practice Address - Country:US
Practice Address - Phone:270-887-9066
Practice Address - Fax:270-887-9199
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31011207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000050781OtherANTHEM
KY110090936OtherMEDICARE RAILROAD
1902803513OtherNPI
KY64310113Medicaid
KY7493OtherMEDICARE GROUP
KY000000050781OtherANTHEM
KY7493OtherMEDICARE GROUP