Provider Demographics
NPI:1295716942
Name:SHAH, SARGAM (RPT)
Entity type:Individual
Prefix:
First Name:SARGAM
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2872 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1669
Mailing Address - Country:US
Mailing Address - Phone:260-497-0838
Mailing Address - Fax:260-497-9088
Practice Address - Street 1:2872 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1669
Practice Address - Country:US
Practice Address - Phone:260-497-0838
Practice Address - Fax:260-497-9088
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007841A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic