Provider Demographics
NPI:1073892337
Name:VIJAY SHAH PHYSICIAN PC
Entity Type:Organization
Organization Name:VIJAY SHAH PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-805-2241
Mailing Address - Street 1:17 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1512
Mailing Address - Country:US
Mailing Address - Phone:631-805-2241
Mailing Address - Fax:718-204-7470
Practice Address - Street 1:17 GORDON DR
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1512
Practice Address - Country:US
Practice Address - Phone:631-805-2241
Practice Address - Fax:718-204-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200343207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01642713Medicaid
G24385Medicare UPIN
NYA100053298Medicare PIN
NY01642713Medicaid