Provider Demographics
NPI:1538152624
Name:SHAH, MUBARIK AHMAD (MD)
Entity type:Individual
Prefix:
First Name:MUBARIK
Middle Name:AHMAD
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MUBARIK
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6248 STONE HILL CT
Mailing Address - Street 2:
Mailing Address - City:PORT TOBACCO
Mailing Address - State:MD
Mailing Address - Zip Code:20677-3403
Mailing Address - Country:US
Mailing Address - Phone:267-909-3310
Mailing Address - Fax:301-934-4678
Practice Address - Street 1:6248 STONE HILL CT
Practice Address - Street 2:
Practice Address - City:PORT TOBACCO
Practice Address - State:MD
Practice Address - Zip Code:20677-3403
Practice Address - Country:US
Practice Address - Phone:267-909-3310
Practice Address - Fax:301-934-4678
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-04-08
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2007-10-18
Provider Licenses
StateLicense IDTaxonomies
FLME89362208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270463300Medicaid
FL48756OtherBCBS
48756AMedicare PIN
FL48756OtherBCBS
FLK6543Medicare ID - Type Unspecified