Provider Demographics
NPI:1790969343
Name:MUKESH D. SHAH, OB-GYN P.C.
Entity Type:Organization
Organization Name:MUKESH D. SHAH, OB-GYN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:DHIRAJLAL
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-724-4017
Mailing Address - Street 1:1656 CHAMPLIN AVE
Mailing Address - Street 2:SUITE # 224
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-724-4017
Mailing Address - Fax:315-793-3689
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:SUITE # 224
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-724-4017
Practice Address - Fax:315-793-3689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165131207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00796901Medicaid
NYAA0180OtherMEDICARE GROUP
NYBB3954Medicare PIN