=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518035732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD SHALTS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 01/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9520 63RD RD STE H
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-864-2120
-----------------------------------------------------
Fax | 888-603-6374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 RIVER RD SUITE 32-79
-----------------------------------------------------
City | EDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07020-1171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-301-2578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 209237
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------