Healthcare Provider Details

I. General information

NPI: 1255726899
Provider Name (Legal Business Name): NIKHIL SHYAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 OLD EAGLE SCHOOL RD STE 304F
WAYNE PA
19087-1701
US

IV. Provider business mailing address

995 OLD EAGLE SCHOOL RD STE 304F
WAYNE PA
19087-1701
US

V. Phone/Fax

Practice location:
  • Phone: 610-688-3099
  • Fax: 610-687-5350
Mailing address:
  • Phone: 610-688-3099
  • Fax: 610-687-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number300052
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD472334
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: