Healthcare Provider Details

I. General information

NPI: 1558351700
Provider Name (Legal Business Name): DHIRAJ M SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 MYRTLE AVE., SUITE 5 THE VASCULAR GROUP, PLLC
ALBANY NY
12208-3412
US

IV. Provider business mailing address

391 MYRTLE AVE STE 5
ALBANY NY
12208-3797
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5640
  • Fax: 518-262-9413
Mailing address:
  • Phone: 518-262-5640
  • Fax: 518-262-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number119380
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number119380
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number119380
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: