Provider Demographics
NPI:1821376211
Name:SHAH, SHRUTI M
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:M
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 1:8 TECHNOLOGY DR
Mailing Address - Street 2:104
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 TECHNOLOGY DR
Practice Address - Street 2:104
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3327
Practice Address - Country:US
Practice Address - Phone:631-689-8662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist