Provider Demographics
NPI:1730280660
Name:KADAM, SHIVAJI L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVAJI
Middle Name:L
Last Name:KADAM
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 1:15 ALBERGO LN
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3847
Mailing Address - Country:US
Mailing Address - Phone:516-496-7917
Mailing Address - Fax:516-496-7917
Practice Address - Street 1:1700 GRAND CONCOURSE
Practice Address - Street 2:SUITE 3F
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7646
Practice Address - Country:US
Practice Address - Phone:718-294-7862
Practice Address - Fax:516-496-7917
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132276207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00447301Medicaid
NY00447301Medicaid
B11550Medicare UPIN