Provider Demographics
NPI:1003951187
Name:SHAH, LISA (DPM)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WIMBLEDON CT
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-1634
Mailing Address - Country:US
Mailing Address - Phone:646-831-5784
Mailing Address - Fax:
Practice Address - Street 1:52 DUANE ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-1207
Practice Address - Country:US
Practice Address - Phone:212-349-7676
Practice Address - Fax:212-349-1882
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005855213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPG9321Medicare ID - Type Unspecified
NYU91346Medicare UPIN