Provider Demographics
NPI:1760669337
Name:SHAH, MANU G
Entity Type:Individual
Prefix:MR
First Name:MANU
Middle Name:G
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1620
Mailing Address - Country:US
Mailing Address - Phone:212-273-5700
Mailing Address - Fax:
Practice Address - Street 1:358 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2209
Practice Address - Country:US
Practice Address - Phone:212-279-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-26
Last Update Date:2008-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01543851Medicaid