Provider Demographics
NPI:1023025798
Name:SHAH, GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:GOPAL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GOPAL
Other - Middle Name:V
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20 GRAND STREET
Mailing Address - Street 2:3RD FL
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-856-5765
Mailing Address - Fax:845-898-7597
Practice Address - Street 1:33 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1805
Practice Address - Country:US
Practice Address - Phone:845-856-5765
Practice Address - Fax:845-856-2535
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33936OtherAETNA HEALTH CARE
NY117350OtherMVP HMO
NY632227OtherUNITED HEALTH
NY141692539OtherEMPIRE PLAN
NY010158750NY01OtherANTHEM PLAN
NYP480818OtherOXFORD HEALTH PLAN
PA1573920Medicaid
NY72D011OtherBLUE CHOICE HMO
NY14162OtherGHI HMO
NY01009067Medicaid
NY141692539OtherCIGNA HEALTHCARE
NYP480818OtherOXFORD HEALTH PLAN
NY010158750NY01OtherANTHEM PLAN
NY14162OtherGHI HMO
A63976Medicare UPIN