Provider Demographics
NPI:1174706253
Name:NADEEM, SHAH (MD)
Entity type:Individual
Prefix:
First Name:SHAH
Middle Name:
Last Name:NADEEM
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 1:2737 SUTTON RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22181-6107
Mailing Address - Country:US
Mailing Address - Phone:301-538-9676
Mailing Address - Fax:703-652-6007
Practice Address - Street 1:FAIRFAX PARK OFFICE PLAZA
Practice Address - Street 2:9512 B LEE HIGHWAY
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2303
Practice Address - Country:US
Practice Address - Phone:703-345-8108
Practice Address - Fax:703-652-6007
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV242632084P0800X
VA01012431012084P0802X, 2084P0800X
CT0463572084P0800X
DEC100086332084P0800X
KY429862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY71000104370Medicaid
WV3810016879Medicaid