=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699771568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN P SHAPIRO MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2005
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 61ST ST SUITE 3A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-8184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-752-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 FIELDSTON RD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10471-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-543-5054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JONATHAN P SHAPIRO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-543-5054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 214518
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------