Provider Demographics
NPI:1770847659
Name:SHAH, JOLLY
Entity Type:Individual
Prefix:MS
First Name:JOLLY
Middle Name:
Last Name:SHAH
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 1:10 SUMMITVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-1827
Mailing Address - Country:US
Mailing Address - Phone:516-922-3104
Mailing Address - Fax:
Practice Address - Street 1:47 HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4022
Practice Address - Country:US
Practice Address - Phone:516-921-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist