Provider Demographics
NPI:1316048796
Name:KIEVAL, SHALOM JOSHUA (MD)
Entity type:Individual
Prefix:DR
First Name:SHALOM
Middle Name:JOSHUA
Last Name:KIEVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2103
Mailing Address - Country:US
Mailing Address - Phone:518-218-1234
Mailing Address - Fax:
Practice Address - Street 1:223 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5964
Practice Address - Country:US
Practice Address - Phone:518-218-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172224207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01045665Medicaid
A56572Medicare UPIN
NY01045665Medicaid