Provider Demographics
NPI:1063481778
Name:SHAHIDULLAH, ABUL B (MD)
Entity Type:Individual
Prefix:
First Name:ABUL
Middle Name:B
Last Name:SHAHIDULLAH
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 1:62-65 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-366-7999
Mailing Address - Fax:718-366-6468
Practice Address - Street 1:62-65 FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-366-7999
Practice Address - Fax:718-366-6468
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187626207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01591217Medicaid
NY02056Medicare PIN
02056Medicare PIN
F77055Medicare UPIN
78I001Medicare PIN
NYF77055Medicare UPIN
NY78I001Medicare PIN