Healthcare Provider Details

I. General information

NPI: 1447558614
Provider Name (Legal Business Name): SHREYAS SURESHBHAI MISTRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MAIN ST
BAY SHORE NY
11706-8408
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 631-968-3000
  • Fax:
Mailing address:
  • Phone: 941-917-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME122478
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101257804
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: