1609409358 NPI number — DR. DEVAN ALEXANDER SHAMBO DPT

Table of content: DR. DEVAN ALEXANDER SHAMBO DPT (NPI 1609409358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609409358 NPI number — DR. DEVAN ALEXANDER SHAMBO DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAMBO
Provider First Name:
DEVAN
Provider Middle Name:
ALEXANDER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1609409358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 UPTOWN RD APT 31
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14850-1602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-633-4375
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 TAUGHANNOCK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850-3251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-277-3861
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  045562 , 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)





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