Provider Demographics
NPI:1295066918
Name:SHAH, SHETAL AMIT (MD)
Entity type:Individual
Prefix:
First Name:SHETAL
Middle Name:AMIT
Last Name:SHAH
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 1:601 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-665-2455
Mailing Address - Fax:631-665-1363
Practice Address - Street 1:601 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-665-2455
Practice Address - Fax:631-665-1363
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5723207W00000X
390200000X
NY258433207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program