Healthcare Provider Details

I. General information

NPI: 1265770085
Provider Name (Legal Business Name): VAHE SIS SHAHNAZARIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 TODT HILL RD STE 203
STATEN ISLAND NY
10314-4528
US

IV. Provider business mailing address

2066 RICHMOND AVE STE 2L
STATEN ISLAND NY
10314-3961
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-1122
  • Fax: 718-448-8318
Mailing address:
  • Phone: 718-448-1122
  • Fax: 718-448-8318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number284847
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number138397
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number284847
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: