Provider Demographics
NPI:1497727606
Name:SHINNICK, TODD RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:RUSSELL
Last Name:SHINNICK
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 1722
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10602-1722
Mailing Address - Country:US
Mailing Address - Phone:914-683-0443
Mailing Address - Fax:914-683-8620
Practice Address - Street 1:30 DAVIS AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1004
Practice Address - Country:US
Practice Address - Phone:914-683-0443
Practice Address - Fax:914-683-8620
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1927752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01443856Medicaid
NY01443856Medicaid
NY161891Medicare ID - Type Unspecified