Healthcare Provider Details

I. General information

NPI: 1780642199
Provider Name (Legal Business Name): RAVINDRA SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST C/O FACULTY PRACTICE
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

374 STOCKHOLM ST C/O FACULTY PRACTICE
BROOKLYN NY
11237-4006
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-6551
  • Fax: 718-963-6793
Mailing address:
  • Phone: 718-963-6551
  • Fax: 718-963-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number149624
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: