Provider Demographics
NPI:1033194568
Name:SHAO, CHARLES Y (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:Y
Last Name:SHAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 CLARKSON AVE
Mailing Address - Street 2:BOX 25
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2056
Mailing Address - Country:US
Mailing Address - Phone:718-270-6755
Mailing Address - Fax:718-270-3313
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:BOX 25
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2056
Practice Address - Country:US
Practice Address - Phone:718-270-6755
Practice Address - Fax:718-270-3313
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219050-1207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI00399Medicare UPIN
NY55R761Medicare ID - Type Unspecified