Provider Demographics
NPI:1306225669
Name:SHYAM SHIVDASANI MD PLLC
Entity Type:Organization
Organization Name:SHYAM SHIVDASANI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:SHALEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVDASANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-242-1430
Mailing Address - Street 1:21 RENI RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1222
Mailing Address - Country:US
Mailing Address - Phone:516-869-3210
Mailing Address - Fax:516-627-0464
Practice Address - Street 1:800 COMMUNITY DR
Practice Address - Street 2:SUITE 207
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3822
Practice Address - Country:US
Practice Address - Phone:516-426-7750
Practice Address - Fax:516-627-0464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196192207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty