Provider Demographics
NPI:1134399306
Name:SHAO, THERESA HUA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:HUA
Last Name:SHAO
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 1:325 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-5903
Mailing Address - Country:US
Mailing Address - Phone:212-604-6058
Mailing Address - Fax:212-604-6039
Practice Address - Street 1:325 W 15TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-5903
Practice Address - Country:US
Practice Address - Phone:212-604-6058
Practice Address - Fax:212-604-6039
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238280207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03245558Medicaid
NY03245558Medicaid