Provider Demographics
NPI:1760480800
Name:SHAH, BHUPENDRA K (MD)
Entity type:Individual
Prefix:
First Name:BHUPENDRA
Middle Name:K
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:PO BOX 12409
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46863-2409
Mailing Address - Country:US
Mailing Address - Phone:260-422-9494
Mailing Address - Fax:260-422-9142
Practice Address - Street 1:2452 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5406
Practice Address - Country:US
Practice Address - Phone:260-422-9494
Practice Address - Fax:260-422-9142
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2009-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030038A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079820AMedicaid
INC24504Medicare UPIN
IN100079820AMedicaid