Provider Demographics
NPI:1124006507
Name:SHAH, PURNA (MD)
Entity Type:Individual
Prefix:
First Name:PURNA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OLD COUNTRY ROAD
Mailing Address - Street 2:#278 LONG ISLAND HEART ASSOCIATES
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501
Mailing Address - Country:US
Mailing Address - Phone:516-877-0977
Mailing Address - Fax:516-294-6861
Practice Address - Street 1:200 OLD COUNTRY ROAD
Practice Address - Street 2:#278 LONG ISLAND HEART ASSOCIATES
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501
Practice Address - Country:US
Practice Address - Phone:516-877-0977
Practice Address - Fax:516-294-6861
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2211851207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02184834Medicaid
212A41Medicare ID - Type Unspecified
NY02184834Medicaid
W35952Medicare ID - Type UnspecifiedGROUP