Provider Demographics
NPI:1609817428
Name:SHAH, VIJAY (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1512
Mailing Address - Country:US
Mailing Address - Phone:718-204-0414
Mailing Address - Fax:718-204-7470
Practice Address - Street 1:444 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3012
Practice Address - Country:US
Practice Address - Phone:718-204-0414
Practice Address - Fax:718-204-7470
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200342174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01642713Medicaid
NY01642713Medicaid
NY094012Medicare PIN