Healthcare Provider Details

I. General information

NPI: 1932212214
Provider Name (Legal Business Name): IRA G. SHAYWITZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

545 ELMONT RD
ELMONT NY
11003-4002
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7037
  • Fax: 540-342-1757
Mailing address:
  • Phone: 516-354-4200
  • Fax: 516-775-1972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number238089
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101253529
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: