Provider Demographics
NPI:1003201179
Name:SHAH, POOJA R (MD)
Entity Type:Individual
Prefix:DR
First Name:POOJA
Middle Name:R
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 1:177 MAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6917
Mailing Address - Country:US
Mailing Address - Phone:631-421-4188
Mailing Address - Fax:
Practice Address - Street 1:177 MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-421-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-05
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY298834207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty