Provider Demographics
NPI:1710449764
Name:SHAH, KISHAN MITESH (MD)
Entity type:Individual
Prefix:DR
First Name:KISHAN
Middle Name:MITESH
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:1353 PASEO DEL PUEBLO SUR STE D
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5958
Practice Address - Country:US
Practice Address - Phone:575-613-8090
Practice Address - Fax:575-613-8091
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0072048207N00000X
NMMD2024-0189207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology