Provider Demographics
NPI:1447237441
Name:SHAH, SHANTILAL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTILAL
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 565
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12748
Mailing Address - Country:US
Mailing Address - Phone:845-482-4171
Mailing Address - Fax:
Practice Address - Street 1:9 TERRACE AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12748
Practice Address - Country:US
Practice Address - Phone:845-482-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113778207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D47852Medicare UPIN
NY955031Medicare ID - Type Unspecified