Healthcare Provider Details

I. General information

NPI: 1275615478
Provider Name (Legal Business Name): ERIC DALE SHAPIRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 MONTAUK HWY
WEST ISLIP NY
11795-4403
US

IV. Provider business mailing address

380 MONTAUK HWY
WEST ISLIP NY
11795-4403
US

V. Phone/Fax

Practice location:
  • Phone: 631-422-6600
  • Fax: 631-422-8503
Mailing address:
  • Phone: 631-422-6600
  • Fax: 631-422-8503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number150306-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: