Healthcare Provider Details

I. General information

NPI: 1669471694
Provider Name (Legal Business Name): JEROME BARRY SHAPIRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 PARK AVE
NEW YORK NY
10028-1061
US

IV. Provider business mailing address

1049 PARK AVE
NEW YORK NY
10028-1061
US

V. Phone/Fax

Practice location:
  • Phone: 917-583-0176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number124545
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: