Provider Demographics
NPI:1265557094
Name:SHAH, INTEZAR H
Entity type:Individual
Prefix:
First Name:INTEZAR
Middle Name:H
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 HASBROUCK RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-5104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BOX 158 ROUTE 17-M
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:10958
Practice Address - Country:US
Practice Address - Phone:845-374-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1937422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY193742Medicaid
NY193742Medicaid