Provider Demographics
NPI:1093931206
Name:SHAN, BALA
Entity Type:Individual
Prefix:MR
First Name:BALA
Middle Name:
Last Name:SHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 BROADWAY
Mailing Address - Street 2:5J
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10040
Mailing Address - Country:US
Mailing Address - Phone:212-304-1802
Mailing Address - Fax:
Practice Address - Street 1:4580 BROADWAY
Practice Address - Street 2:5J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-2105
Practice Address - Country:US
Practice Address - Phone:212-304-1802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist