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NPI Code Detail

MEDICARE: DR. KULSOOM SHAH M.D

MEDICARE: DR. KULSOOM SHAH M.D
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician224192-1NY

General Provider Information

NPI Number : 1114920360
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KULSOOM SHAH M.D
Provider Business Mailing Address
First Line : 52 AVALON CIR
Second Line :
City : SMITHTOWN
State : NY
Zip : 11787-3855
Country : US
Telephone Number : 631-863-1634
Fax Number : 631-632-6936
Provider Business Practice Location Address
First Line : 1 STADIUM RD,STUDENT HEALTH CENTER,STONYBROOK UNIV
Second Line :
City : STONY BROOK
State : NY
Zip : 11794-0001
Country : US
Telephone Number : 631-632-6740
Fax Number : 631-632-6936
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2005
Last Update Date : 07/08/2007

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