Provider Demographics
NPI:1417936501
Name:SHAH, MINAL (MD)
Entity Type:Individual
Prefix:DR
First Name:MINAL
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 947
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-0079
Mailing Address - Country:US
Mailing Address - Phone:516-477-0008
Mailing Address - Fax:516-677-0107
Practice Address - Street 1:110 COACHMAN PLACE WEST
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3052
Practice Address - Country:US
Practice Address - Phone:516-477-0008
Practice Address - Fax:516-677-0107
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189767207R00000X, 208D00000X, 207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01347960Medicaid
122A52Medicare ID - Type Unspecified
W35952Medicare ID - Type UnspecifiedGROUP
F33713Medicare UPIN