Healthcare Provider Details

I. General information

NPI: 1124387048
Provider Name (Legal Business Name): SHUBHA SHASTRY MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2012
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E RIDGE RD
ROCHESTER NY
14621-1240
US

IV. Provider business mailing address

370 E RIDGE RD SUITE 20
ROCHESTER NY
14621-1240
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-0400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number267196
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: