Provider Demographics
NPI:1558351601
Name:SHATLA, AHMED (MD)
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:
Last Name:SHATLA
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 1:210 OLD CAMPION RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1641
Mailing Address - Country:US
Mailing Address - Phone:315-266-2078
Mailing Address - Fax:315-735-3910
Practice Address - Street 1:210 OLD CAMPION RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1641
Practice Address - Country:US
Practice Address - Phone:315-266-2078
Practice Address - Fax:315-735-3910
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214256-1207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02155131Medicaid
NYH40159Medicare UPIN
NYDD0538Medicare ID - Type UnspecifiedMEDICARE