Provider Demographics
NPI:1285733808
Name:GASTON, SHENELLE R (MD)
Entity type:Individual
Prefix:DR
First Name:SHENELLE
Middle Name:R
Last Name:GASTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHENELLE
Other - Middle Name:R
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:942A ROUTE 146
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065
Practice Address - Country:US
Practice Address - Phone:518-371-8000
Practice Address - Fax:518-371-5338
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2111981208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY47368OtherGHI/HMO
NY552441OtherEMPIRE BC
NY01991042Medicaid
NY070216000050OtherFIDELIS
NY000490478001OtherBSNENY
NY10032127OtherCDPHP
NY200063OtherSENIOR WHOLE HEALTH
NY26416OtherMVP
NY7347619OtherAETNA