1306225669 NPI number — SHYAM SHIVDASANI MD PLLC

Table of content: (NPI 1306225669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306225669 NPI number — SHYAM SHIVDASANI MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHYAM SHIVDASANI MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306225669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 RENI RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHASSET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11030-1222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-869-3210
Provider Business Mailing Address Fax Number:
516-627-0464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 COMMUNITY DR
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
MANHASSET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11030-3822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-426-7750
Provider Business Practice Location Address Fax Number:
516-627-0464
Provider Enumeration Date:
05/20/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHIVDASANI
Authorized Official First Name:
SHALEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
516-242-1430

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  196192 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)