Healthcare Provider Details

I. General information

NPI: 1124006507
Provider Name (Legal Business Name): PURNA SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 05/04/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DARIUS CT
DIX HILLS NY
11746-5340
US

IV. Provider business mailing address

6 DARIUS CT
DIX HILLS NY
11746-5340
US

V. Phone/Fax

Practice location:
  • Phone: 888-433-2700
  • Fax:
Mailing address:
  • Phone: 888-433-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2211851
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: