MEDICARE: SUDHA R SHAH

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
1	207Q00000X	Family Medicine Physician	133672	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205924974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUDHA R SHAH

Provider Business Mailing Address
First Line	:	288 BIRCH DR
Second Line	:
City	:	ROSLYN
State	:	NY
Zip	:	11576-3002
Country	:	US
Telephone Number	:	516-567-6135
Fax Number	:	718-258-1768

Provider Business Practice Location Address
First Line	:	3860 KINGS HWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2907
Country	:	US
Telephone Number	:	718-252-5550
Fax Number	:	718-258-1768

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	03/01/2012

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Directions to “ SUDHA R SHAH ” Practice Location

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