Provider Demographics
NPI:1972563898
Name:MOZUMDAR, SHAYMAL (MD)
Entity Type:Individual
Prefix:
First Name:SHAYMAL
Middle Name:
Last Name:MOZUMDAR
Suffix:
Gender:M
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:3735 NAZARETH RD STE 301
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-8347
Practice Address - Country:US
Practice Address - Phone:610-829-2200
Practice Address - Fax:610-829-2211
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192233207R00000X
PAMD449953207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100918OtherGHI
NY0409243OtherINDEPENDENT HEALTH
NY000523007009OtherBLUE CROSS
NY040426003599OtherFIDELIS
110235049OtherRAILROAD MEDICARE
145302BJOtherPREFERRED CARE
NY01476613Medicaid
NY00020501801OtherUNIVERA
NY00020501801OtherUNIVERA
F65929Medicare UPIN