Provider Demographics
NPI:1265495600
Name:SHAMOW, JEFFREY M
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:SHAMOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ABBOT RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2355
Mailing Address - Country:US
Mailing Address - Phone:631-366-3780
Mailing Address - Fax:631-647-7893
Practice Address - Street 1:160 HOWELLS RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5320
Practice Address - Country:US
Practice Address - Phone:631-647-7885
Practice Address - Fax:631-647-7893
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011241103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01473596Medicaid
NY01473596Medicaid