Provider Demographics
NPI:1619936671
Name:SHAH, BHARAT R
Entity Type:Individual
Prefix:DR
First Name:BHARAT
Middle Name:R
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:BHARART
Other - Middle Name:R
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:24 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1423
Mailing Address - Country:US
Mailing Address - Phone:516-939-0056
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2290
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:631-744-5308
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY145555-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology