Healthcare Provider Details

I. General information

NPI: 1235798943
Provider Name (Legal Business Name): MICHELLE SHANKAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 EASTCHESTER RD
BRONX NY
10461-2604
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 718-405-8040
  • Fax:
Mailing address:
  • Phone: 187-920-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number72559
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT218202
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: