Provider Demographics
NPI:1073574398
Name:SHAH, UDAY NIRANJAN (MD)
Entity Type:Individual
Prefix:DR
First Name:UDAY
Middle Name:NIRANJAN
Last Name:SHAH
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 1:2156 IRONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MUTTONTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11791-9662
Mailing Address - Country:US
Mailing Address - Phone:516-921-2476
Mailing Address - Fax:516-921-0985
Practice Address - Street 1:4112 JUDGE ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2344
Practice Address - Country:US
Practice Address - Phone:718-779-6666
Practice Address - Fax:516-651-3053
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0225560207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02355604Medicaid
H68268Medicare UPIN
093AY1Medicare PIN
NY02355604Medicaid