Provider Demographics
NPI:1720585672
Name:MARDER, SHIRA
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:MARDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SANFORD LN
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-2819
Mailing Address - Country:US
Mailing Address - Phone:914-420-0349
Mailing Address - Fax:
Practice Address - Street 1:210 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2901
Practice Address - Country:US
Practice Address - Phone:914-682-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-08
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30683601207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine