Provider Demographics
NPI:1730157561
Name:SHAH, SANJIV A (MD)
Entity type:Individual
Prefix:DR
First Name:SANJIV
Middle Name:A
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 1:4371 NARROW LANE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2971
Mailing Address - Country:US
Mailing Address - Phone:334-613-3680
Mailing Address - Fax:334-613-3685
Practice Address - Street 1:124 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3619
Practice Address - Country:US
Practice Address - Phone:334-613-3680
Practice Address - Fax:334-613-3685
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
051002492OtherBLUE CROSS BLUE SHIELD
AL009932223Medicaid
051556549Medicare ID - Type Unspecified
051002492OtherBLUE CROSS BLUE SHIELD