Provider Demographics
NPI:1134516677
Name:MAYANK SHAH PHYSICIAN PC
Entity Type:Organization
Organization Name:MAYANK SHAH PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYANK
Authorized Official - Middle Name:PRATAPRAI
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-986-8670
Mailing Address - Street 1:200 RONALD REAGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-4107
Mailing Address - Country:US
Mailing Address - Phone:845-986-8670
Mailing Address - Fax:845-987-1348
Practice Address - Street 1:200 RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-4107
Practice Address - Country:US
Practice Address - Phone:845-986-8670
Practice Address - Fax:845-987-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171978261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service