Provider Demographics
NPI:1598872616
Name:SHAH, MAYANK P (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYANK
Middle Name:P
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990
Mailing Address - Country:US
Mailing Address - Phone:845-986-8670
Mailing Address - Fax:845-987-1348
Practice Address - Street 1:200 RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990
Practice Address - Country:US
Practice Address - Phone:845-986-8670
Practice Address - Fax:845-987-1348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171978207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01052813Medicaid
NY18E961OtherBLUECROSS BLUESHIELD
NYA61057Medicare UPIN
NY18E961OtherBLUECROSS BLUESHIELD