Basic Information
| Provider Information | |||||||||
| NPI: | 1417992447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | SHITAL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 OREGON PK. | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176014890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172933223 | ||||||||
| FaxNumber: | 7173902455 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 SPARTA AVE. | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SPARTA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078711777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737290002 | ||||||||
| FaxNumber: | 9737264456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/05/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 214028 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA08249100 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0188131 | 05 | NJ | MEDICAID |