Provider Demographics
NPI:1922084383
Name:SHAFFRAN, MINDY LYNN
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LYNN
Last Name:SHAFFRAN
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 1:118 NORTH COUNTRY ROAD
Mailing Address - Street 2:SUFFOLK OB/GYN, LLP
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-473-7171
Mailing Address - Fax:631-473-4605
Practice Address - Street 1:118 NORTH COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-473-7171
Practice Address - Fax:631-473-4605
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167389207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160037800OtherRAILROAD MEDICARE
NY15E831Medicare ID - Type Unspecified
NY15E831Medicare PIN
B05302Medicare UPIN