Provider Demographics
NPI:1023100914
Name:SHAH, INDRAVADAN KESHAVLAL (MD)
Entity type:Individual
Prefix:DR
First Name:INDRAVADAN
Middle Name:KESHAVLAL
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 1:2339 MCCALLIE AVE
Mailing Address - Street 2:SUITT # 203
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-624-3406
Mailing Address - Fax:423-624-7657
Practice Address - Street 1:2339 MCCALLIE AVE
Practice Address - Street 2:SUITT # 203
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-624-3406
Practice Address - Fax:423-624-7657
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15736207RR0500X
GA19472207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3-00910-5Medicaid
GA00311627AMedicaid
TN3-00910-5Medicare ID - Type Unspecified
TN3-00910-5Medicaid