Healthcare Provider Details

I. General information

NPI: 1962021774
Provider Name (Legal Business Name): SHANE ASHFORD ENDICOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

IV. Provider business mailing address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 516-572-6501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME173775
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: