Provider Demographics
NPI:1952358038
Name:HAIDER-SHAH, SYED A (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:A
Last Name:HAIDER-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:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0340
Mailing Address - Country:US
Mailing Address - Phone:315-732-9368
Mailing Address - Fax:315-732-9403
Practice Address - Street 1:1705 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5642
Practice Address - Country:US
Practice Address - Phone:315-797-0900
Practice Address - Fax:315-797-0900
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122493-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00462139Medicaid
DCAH6537736OtherDEA
DCAH6537736OtherDEA
NY00462139Medicaid