Provider Demographics
NPI:1114920360
Name:SHAH, KULSOOM (MD)
Entity Type:Individual
Prefix:DR
First Name:KULSOOM
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:52 AVALON CIR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3855
Mailing Address - Country:US
Mailing Address - Phone:631-863-1634
Mailing Address - Fax:631-632-6936
Practice Address - Street 1:1 STADIUM RD,STUDENT HEALTH CENTER,STONYBROOK UNIV
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-632-6740
Practice Address - Fax:631-632-6936
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY224192-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG21951Medicare UPIN