Provider Demographics
NPI:1275554305
Name:BAKHTIAR A SHAH MD PC
Entity Type:Organization
Organization Name:BAKHTIAR A SHAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BAKHTIAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-815-1000
Mailing Address - Street 1:302 MANOR ROAD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-815-1000
Mailing Address - Fax:718-815-8122
Practice Address - Street 1:130 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-6362
Practice Address - Country:US
Practice Address - Phone:718-815-1000
Practice Address - Fax:718-815-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWANU71OtherGRP MCR
NYWEX631Medicare ID - Type Unspecified
NYF70270Medicare UPIN
NYWANU71OtherGRP MCR