Provider Demographics
NPI:1770775025
Name:SHALOMOV, ALBERT (MD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:SHALOMOV
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 1:6433 99TH ST APT 4L
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3543
Mailing Address - Country:US
Mailing Address - Phone:718-757-6224
Mailing Address - Fax:
Practice Address - Street 1:10721 QUEENS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4413
Practice Address - Country:US
Practice Address - Phone:718-520-0857
Practice Address - Fax:718-520-9099
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244590207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00669Medicare PIN