Provider Demographics
NPI:1144229584
Name:SHAH, SHAILESH J (MD)
Entity type:Individual
Prefix:
First Name:SHAILESH
Middle Name:J
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 1:1385 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-3414
Mailing Address - Country:US
Mailing Address - Phone:978-957-6675
Mailing Address - Fax:978-957-5887
Practice Address - Street 1:1385 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:DRACUT
Practice Address - State:MA
Practice Address - Zip Code:01826-3414
Practice Address - Country:US
Practice Address - Phone:978-957-6675
Practice Address - Fax:978-957-5887
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2011-07-21
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MA58096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA058096OtherTUFTS HEALTH PLAN
MA981952OtherNETWORK HEALTH
MA20432OtherHARVARD PILGRIM
MA3024491Medicaid
MAB11056101OtherCIGNA
MAJ06526OtherBLUE CROSS BLUE SHIELD MA
MA11258OtherFALLON
MA4041104OtherAETNA
MA12-01159OtherUNITED HEALTHCARE
MA4041104OtherAETNA