Provider Demographics
NPI:1841276763
Name:SHAH, SIDDHARTHA S (MD)
Entity type:Individual
Prefix:
First Name:SIDDHARTHA
Middle Name:S
Last Name:SHAH
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 1:60 MAPLE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2917
Mailing Address - Country:US
Mailing Address - Phone:716-626-5250
Mailing Address - Fax:716-332-2218
Practice Address - Street 1:60 MAPLE RD
Practice Address - Street 2:STE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2917
Practice Address - Country:US
Practice Address - Phone:716-626-5250
Practice Address - Fax:716-332-2218
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179451207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100013189OtherRAILROAD NEDICARE
NY153030BTOtherPREFERRED CARE
NY00010162901OtherUNIVERA
NY000511391004OtherBLUE CROSS OF WNY
NY2307716OtherINDEPENDENT HEALTH
NY2499566OtherGHI
NY01339624Medicaid
NY5289777OtherAETNA
NY040426001814OtherFIDELIS
NY00010162901OtherUNIVERA
NY5289777OtherAETNA