Provider Demographics
NPI:1659356715
Name:SHAH, KAUSHAL (MD)
Entity Type:Individual
Prefix:DR
First Name:KAUSHAL
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 1:475 STATE ROUTE 17M
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4169
Mailing Address - Country:US
Mailing Address - Phone:845-333-7830
Mailing Address - Fax:845-333-7475
Practice Address - Street 1:475 STATE ROUTE 17M
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4169
Practice Address - Country:US
Practice Address - Phone:845-333-7830
Practice Address - Fax:845-333-7475
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211335207R00000X, 2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79095Medicare UPIN
NY42C711Medicare ID - Type Unspecified