Healthcare Provider Details

I. General information

NPI: 1033299490
Provider Name (Legal Business Name): SHYAM TUKARAM PATIL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WILBUR ROAD NEW YORK STATE HVDDSO
THIELLS NY
10984-0470
US

IV. Provider business mailing address

11 WILBUR ROAD NEW YORK STATE HVDDSO
THIELLS NY
10984-0470
US

V. Phone/Fax

Practice location:
  • Phone: 845-947-6220
  • Fax: 845-947-6240
Mailing address:
  • Phone: 845-947-6220
  • Fax: 845-947-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number153502-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: