Provider Demographics
NPI:1780678136
Name:PEDOEM-SHAPIRO, MINOO (MD)
Entity Type:Individual
Prefix:
First Name:MINOO
Middle Name:
Last Name:PEDOEM-SHAPIRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 TEMPLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5510
Mailing Address - Country:US
Mailing Address - Phone:845-562-2191
Mailing Address - Fax:845-562-2295
Practice Address - Street 1:448 TEMPLE HILL RD
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-5510
Practice Address - Country:US
Practice Address - Phone:845-562-2191
Practice Address - Fax:845-562-2295
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01155302Medicaid
NY01155302Medicaid