Healthcare Provider Details

I. General information

NPI: 1801967963
Provider Name (Legal Business Name): KIRAN DAMODAR SHAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE DEPARTMENT OF PEDIATRICS
NEW YORK NY
10029-7404
US

IV. Provider business mailing address

6 SARATOGA CT
NANUET NY
10954-3112
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6228
  • Fax:
Mailing address:
  • Phone: 845-627-7032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number165396
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: