Provider Demographics
NPI:1114947157
Name:SAMUEL, SHELBY KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:KEVIN
Last Name:SAMUEL
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:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10602-0391
Mailing Address - Country:US
Mailing Address - Phone:718-498-7888
Mailing Address - Fax:718-604-7890
Practice Address - Street 1:200 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1908
Practice Address - Country:US
Practice Address - Phone:718-498-7888
Practice Address - Fax:718-604-7890
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176352207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01448966Medicaid
NYF61761Medicare UPIN
NY01448966Medicaid