Provider Demographics
NPI:1205924974
Name:SHAH, SUDHA R
Entity type:Individual
Prefix:
First Name:SUDHA
Middle Name:R
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 1:288 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3002
Mailing Address - Country:US
Mailing Address - Phone:516-567-6135
Mailing Address - Fax:718-258-1768
Practice Address - Street 1:3860 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2907
Practice Address - Country:US
Practice Address - Phone:718-252-5550
Practice Address - Fax:718-258-1768
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00346814Medicaid
NY25A231Medicare ID - Type Unspecified
C07196Medicare UPIN