Provider Demographics
NPI:1558445973
Name:SHAH, SURENDRALAL G (MD)
Entity Type:Individual
Prefix:
First Name:SURENDRALAL
Middle Name:G
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 1:528 OLD COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4997
Mailing Address - Country:US
Mailing Address - Phone:516-822-4706
Mailing Address - Fax:516-822-1373
Practice Address - Street 1:528 OLD COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4997
Practice Address - Country:US
Practice Address - Phone:516-822-4706
Practice Address - Fax:516-822-1373
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133617207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00725493Medicaid
NYA400024012Medicare PIN
NY00725493Medicaid