Provider Demographics
NPI:1124048376
Name:MATHUR, SHAILENDRA (DPM)
Entity type:Individual
Prefix:DR
First Name:SHAILENDRA
Middle Name:
Last Name:MATHUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16015 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1019
Mailing Address - Country:US
Mailing Address - Phone:718-926-2615
Mailing Address - Fax:718-969-0403
Practice Address - Street 1:9876 QUEENS BLVD
Practice Address - Street 2:SUITE 1K
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4356
Practice Address - Country:US
Practice Address - Phone:718-897-0300
Practice Address - Fax:718-897-3330
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005757213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386414Medicaid
NYU92571Medicare UPIN
NYPM1982Medicare ID - Type UnspecifiedPODIATRY