Provider Demographics
NPI:1003830886
Name:BERSON, SHELLEY R (MD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:R
Last Name:BERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2 STRAWTOWN ROAD
Mailing Address - Street 2:SUITES 6 & 7
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994
Mailing Address - Country:US
Mailing Address - Phone:845-727-1340
Mailing Address - Fax:845-727-1349
Practice Address - Street 1:2 STRAWTOWN RD
Practice Address - Street 2:SUITES 6 & 7
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1847
Practice Address - Country:US
Practice Address - Phone:845-727-1340
Practice Address - Fax:845-727-1349
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-06-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY173585207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02153667Medicaid
NY02153667Medicaid
NYF20755Medicare UPIN