Provider Demographics
NPI:1124205893
Name:SHAH, DIPI RAVI (MS)
Entity Type:Individual
Prefix:MRS
First Name:DIPI
Middle Name:RAVI
Last Name:SHAH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 RANO BLVD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2938
Mailing Address - Country:US
Mailing Address - Phone:607-729-6010
Mailing Address - Fax:
Practice Address - Street 1:34 W STATE ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2311
Practice Address - Country:US
Practice Address - Phone:607-722-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040455-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist