Provider Demographics
NPI:1053965392
Name:SHAH, DHIRAJ (MD)
Entity type:Individual
Prefix:
First Name:DHIRAJ
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 1:330 N WABASH AVE STE G-20
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2605
Mailing Address - Country:US
Mailing Address - Phone:765-660-7616
Mailing Address - Fax:
Practice Address - Street 1:441 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2612
Practice Address - Country:US
Practice Address - Phone:765-662-4236
Practice Address - Fax:765-662-4903
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087976A208M00000X, 207R00000X
MA280032390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102638432OtherANTHEM