Provider Demographics
NPI:1871977793
Name:SHAH, PRATIK (MD)
Entity type:Individual
Prefix:
First Name:PRATIK
Middle Name:
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:PO BOX 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8812
Mailing Address - Fax:
Practice Address - Street 1:7211 BANK CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8483
Practice Address - Country:US
Practice Address - Phone:240-566-7830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD89673207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program