Healthcare Provider Details

I. General information

NPI: 1871174177
Provider Name (Legal Business Name): JACOB CHARLES SHAMASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

15 STUYVESANT OVAL APT 1D
NEW YORK NY
10009-2046
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4321
  • Fax:
Mailing address:
  • Phone: 732-740-0215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number326833-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: