Healthcare Provider Details

I. General information

NPI: 1245579226
Provider Name (Legal Business Name): SHIVANI S SHAH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 CANAL ST STE 200
STATEN ISLAND NY
10304
US

IV. Provider business mailing address

46 ALBION ST
BRIDGEPORT CT
06605-2602
US

V. Phone/Fax

Practice location:
  • Phone: 917-830-1950
  • Fax:
Mailing address:
  • Phone: 646-724-0532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number292168
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number292168
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: