Provider Demographics
NPI:1902854086
Name:SHAH, JYOTI R (MD DFAPA)
Entity Type:Individual
Prefix:DR
First Name:JYOTI
Middle Name:R
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD DFAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 STANLEY DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5610
Mailing Address - Country:US
Mailing Address - Phone:570-288-3903
Mailing Address - Fax:570-288-3903
Practice Address - Street 1:354 STANLEY DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5610
Practice Address - Country:US
Practice Address - Phone:570-288-3903
Practice Address - Fax:570-288-3903
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 023979E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1456970Medicaid
PASH698042Medicare ID - Type Unspecified
PA1456970Medicaid