Provider Demographics
NPI:1164791190
Name:SUDHA R SHAH MD PC
Entity Type:Organization
Organization Name:SUDHA R SHAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUDHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-252-5550
Mailing Address - Street 1:3860 KINGS HWY
Mailing Address - Street 2:#1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2907
Mailing Address - Country:US
Mailing Address - Phone:718-252-5550
Mailing Address - Fax:718-258-1768
Practice Address - Street 1:3860 KINGS HWY
Practice Address - Street 2:#1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2907
Practice Address - Country:US
Practice Address - Phone:718-252-5550
Practice Address - Fax:718-258-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133672261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00346814Medicaid