Provider Demographics
NPI:1215020011
Name:SHAH, MAHENDRA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHENDRA
Middle Name:G
Last Name:SHAH
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:P.O. BOX 625
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792
Mailing Address - Country:US
Mailing Address - Phone:631-929-8787
Mailing Address - Fax:631-929-0350
Practice Address - Street 1:1866 WADING RIVER MANOR ROAD
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792
Practice Address - Country:US
Practice Address - Phone:631-929-8787
Practice Address - Fax:631-929-0350
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00558567Medicaid
NY15A681OtherPTAN
NYB77654Medicare UPIN