Provider Demographics
NPI:1871728907
Name:SHAH, JAY PRAVIN (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:PRAVIN
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 1:125 GUADALUPE DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3334
Mailing Address - Country:US
Mailing Address - Phone:708-525-6915
Mailing Address - Fax:
Practice Address - Street 1:4301 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6497
Practice Address - Country:US
Practice Address - Phone:708-525-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131055207XX0005X
TXP8731207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348517902Medicaid
TX348517901Medicaid
TX348517903Medicaid
TX430397YL7AMedicare PIN
TX348517903Medicaid
TX430397YNGSMedicare PIN