Provider Demographics
NPI:1679753073
Name:PRAKASH SHAH MD
Entity type:Organization
Organization Name:PRAKASH SHAH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAKASH
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-887-9066
Mailing Address - Street 1:1724 KENTON ST
Mailing Address - Street 2:SUITE 1-D
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1981
Mailing Address - Country:US
Mailing Address - Phone:270-887-9066
Mailing Address - Fax:270-887-9199
Practice Address - Street 1:1724 KENTON ST
Practice Address - Street 2:SUITE 1-D
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1981
Practice Address - Country:US
Practice Address - Phone:270-887-9066
Practice Address - Fax:270-887-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31011207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64310113Medicaid
KY000000050781OtherANTHEM
KY110090936OtherMEDICARE RAILROAD
KY000000050781OtherANTHEM
KYF87352Medicare UPIN
KY64310113Medicaid