Provider Demographics
NPI:1114264132
Name:JYOTI M SHAH PHYSICIAN P C
Entity Type:Organization
Organization Name:JYOTI M SHAH PHYSICIAN P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JYOTI
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-410-4792
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0270
Mailing Address - Country:US
Mailing Address - Phone:631-264-2035
Mailing Address - Fax:
Practice Address - Street 1:18811 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1935
Practice Address - Country:US
Practice Address - Phone:718-264-6703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169615207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty