Provider Demographics
NPI:1033222468
Name:SHIVDASANI, SHYAM CHANDRU (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAM
Middle Name:CHANDRU
Last Name:SHIVDASANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:21 RENI RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1222
Mailing Address - Country:US
Mailing Address - Phone:516-869-3210
Mailing Address - Fax:516-627-0464
Practice Address - Street 1:140 LOCKWOOD AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4915
Practice Address - Country:US
Practice Address - Phone:914-235-6900
Practice Address - Fax:914-235-7900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196192207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3359089OtherAETNA HMO ID#
NY01851505Medicaid
NY002918OtherCONNECTICARE ID#
NY196192OtherHIP ID #
NY3C2846OtherPHS HEALTHNET ID#
NY5387184OtherAETNA PPO ID#
NY163AJ3OtherEMPIRE BC/BS ID #
NYP00311425OtherMEDICARE RAILROAD
NYWP738OtherOXFORD ID #
NY2592106OtherGHI ID #
NY1033222468OtherCOMMERICAL CARRIERS
NYP00311425OtherMEDICARE RAILROAD
NYF99592Medicare UPIN