MEDICARE: DR. INDRAVADAN C 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
1	207Q00000X	Family Medicine Physician	110048	NY
2	208600000X	Surgery Physician	110048	NY

General Provider Information

NPI Number	:	1467537746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. INDRAVADAN C SHAH M.D.

Provider Business Mailing Address
First Line	:	454 E SHORE RD
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11024-1540
Country	:	US
Telephone Number	:	516-487-3924
Fax Number	:	516-487-3924

Provider Business Practice Location Address
First Line	:	454 E SHORE RD
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11024-1540
Country	:	US
Telephone Number	:	516-487-3924
Fax Number	:	516-487-3924

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	09/11/2025

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