Provider Demographics
NPI:1124006507
Name:SHAH, PURNA (MD)
Entity type:Individual
Prefix:
First Name:PURNA
Middle Name:
Last Name:SHAH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DARIUS CT
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5340
Mailing Address - Country:US
Mailing Address - Phone:888-433-2700
Mailing Address - Fax:
Practice Address - Street 1:6 DARIUS CT
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5340
Practice Address - Country:US
Practice Address - Phone:888-433-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2211851207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02184834Medicaid
212A41Medicare ID - Type Unspecified
NY02184834Medicaid
W35952Medicare ID - Type UnspecifiedGROUP