Provider Demographics
NPI:1619167673
Name:SHAH, AYYAZ M (DO)
Entity Type:Individual
Prefix:
First Name:AYYAZ
Middle Name:M
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1559
Practice Address - Country:US
Practice Address - Phone:607-658-1003
Practice Address - Fax:607-658-1006
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10163207N00000X
NY203641207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001992700Medicaid