Provider Demographics
NPI:1114920436
Name:WANI, SHAFI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAFI
Middle Name:
Last Name:WANI
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 1:2500 NESCONSET HWY
Mailing Address - Street 2:BLDG 15H
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2554
Mailing Address - Country:US
Mailing Address - Phone:631-689-3005
Mailing Address - Fax:631-689-1750
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BLDG 15H
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2554
Practice Address - Country:US
Practice Address - Phone:631-689-3005
Practice Address - Fax:631-689-1750
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111748174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist