Healthcare Provider Details

I. General information

NPI: 1417936501
Provider Name (Legal Business Name): MINAL SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 COACHMAN PLACE WEST
SYOSSET NY
11791-3052
US

IV. Provider business mailing address

PO BOX 947
SYOSSET NY
11791-0079
US

V. Phone/Fax

Practice location:
  • Phone: 516-477-0008
  • Fax: 516-677-0107
Mailing address:
  • Phone: 516-477-0008
  • Fax: 516-677-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number189767
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number189767
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number189767
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number189767
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: