Provider Demographics
NPI:1326041211
Name:SHAH, PRAVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVIN
Middle Name:
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:PO BOX 5801
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5801
Mailing Address - Country:US
Mailing Address - Phone:914-593-7880
Mailing Address - Fax:914-593-7881
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:STE 700
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-593-7800
Practice Address - Fax:914-593-7881
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1178602086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY97E613K223OtherPTAN
NY00549853Medicaid
NY97E6133641OtherPTAN
NY97E613K221OtherPTAN
NY770002078OtherRAIL ROAD MEDICARE
NY97E613K222OtherPTAN
NY97E613K221OtherPTAN
NY293921Medicare ID - Type Unspecified