=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346621869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEJAL SHAH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2015
-----------------------------------------------------
Last Update Date | 10/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 DOGWOOD AVE
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-3447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-481-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14616 BLACKBURN RD
-----------------------------------------------------
City | BURTONSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20866-3113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-305-1320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 296211
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------