Provider Demographics
NPI:1629079249
Name:SHAH, SURYAKANT (MD)
Entity Type:Individual
Prefix:
First Name:SURYAKANT
Middle Name:
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 1:1890 PALMER AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-3031
Mailing Address - Country:US
Mailing Address - Phone:914-834-9606
Mailing Address - Fax:914-834-0648
Practice Address - Street 1:1890 PALMER AVE STE 304
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-3031
Practice Address - Country:US
Practice Address - Phone:914-834-9606
Practice Address - Fax:914-834-0648
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228300-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA900061973Medicare PIN
C34459Medicare UPIN