Provider Demographics
NPI:1518220334
Name:SHAHA, MAMTA A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMTA
Middle Name:A
Last Name:SHAHA
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 1:12 SPLIT ROCK DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1127
Mailing Address - Country:US
Mailing Address - Phone:516-487-1852
Mailing Address - Fax:
Practice Address - Street 1:12 SPLIT ROCK DR
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11024-1127
Practice Address - Country:US
Practice Address - Phone:516-487-1852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY146203208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics