Provider Demographics
NPI:1326135690
Name:SHAH, JYOTINDRA G (MD)
Entity Type:Individual
Prefix:DR
First Name:JYOTINDRA
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 1:20 ILINKA LN
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533-2333
Mailing Address - Country:US
Mailing Address - Phone:914-591-6770
Mailing Address - Fax:
Practice Address - Street 1:3455 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-2508
Practice Address - Country:US
Practice Address - Phone:718-798-2236
Practice Address - Fax:718-798-0561
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00271150Medicaid
NY00271150Medicaid
NY33943Medicare ID - Type Unspecified