Provider Demographics
NPI:1003169756
Name:SHAH, KUNJAN (PT)
Entity Type:Individual
Prefix:
First Name:KUNJAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 72ND ST
Mailing Address - Street 2:JACKSON HEIGHTS
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-1036
Mailing Address - Country:US
Mailing Address - Phone:815-575-5518
Mailing Address - Fax:
Practice Address - Street 1:675 3RD AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5704
Practice Address - Country:US
Practice Address - Phone:212-204-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist