Provider Demographics
NPI:1861411373
Name:SHAH, BHAVNA RAJESH (MD)
Entity type:Individual
Prefix:DR
First Name:BHAVNA
Middle Name:RAJESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4907 COUNTRY LN
Mailing Address - Street 2:P O BOX 4363
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9787
Mailing Address - Country:US
Mailing Address - Phone:517-784-3406
Mailing Address - Fax:517-784-6891
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-788-4897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048648208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2503800652OtherBCBS ID NUMBER
MI1671387#10Medicaid
MI1671387#10Medicaid
MIAS3256054OtherDEA NUMBER
03800653252Medicare ID - Type Unspecified