Provider Demographics
NPI:1871534925
Name:SHAH, BOBBY AJAY (MD)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:AJAY
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 1:825 E LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5803
Mailing Address - Country:US
Mailing Address - Phone:219-464-4891
Mailing Address - Fax:219-464-1873
Practice Address - Street 1:3275 SW DARWIN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3317
Practice Address - Country:US
Practice Address - Phone:800-437-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056041A2085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200382730Medicaid
IN300135676OtherRR MEDICARE