Provider Demographics
NPI:1174738413
Name:SHAH, KAVITA K (MD)
Entity type:Individual
Prefix:
First Name:KAVITA
Middle Name:K
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S HARVARD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3023
Mailing Address - Country:US
Mailing Address - Phone:918-403-4120
Mailing Address - Fax:
Practice Address - Street 1:4720 S HARVARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3023
Practice Address - Country:US
Practice Address - Phone:918-403-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28092207R00000X, 207RE0101X
AZ77175207R00000X
TXP7348207R00000X
CODR.0071548207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200306790AMedicaid