Provider Demographics
NPI:1437141785
Name:SHAH, PRATIBHA PRAVIN (MD)
Entity Type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:PRAVIN
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-1501
Mailing Address - Country:US
Mailing Address - Phone:845-469-6866
Mailing Address - Fax:845-469-6855
Practice Address - Street 1:11 WEST AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-1501
Practice Address - Country:US
Practice Address - Phone:845-469-6866
Practice Address - Fax:845-469-6855
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
NY190497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G38665Medicare UPIN