Provider Demographics
NPI:1801029046
Name:SONNAD, SHANTALA (MD)
Entity Type:Individual
Prefix:
First Name:SHANTALA
Middle Name:
Last Name:SONNAD
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 1:1351 ROUTE 55 STE 200
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5128
Mailing Address - Country:US
Mailing Address - Phone:845-475-9661
Mailing Address - Fax:845-475-9938
Practice Address - Street 1:1100 ROUTE 55 STE 101
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540
Practice Address - Country:US
Practice Address - Phone:845-473-0974
Practice Address - Fax:845-473-5380
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03550112Medicaid