Provider Demographics
NPI:1972580215
Name:MAYBODY, SHIDEH SHAFINOORI (MD)
Entity type:Individual
Prefix:
First Name:SHIDEH
Middle Name:SHAFINOORI
Last Name:MAYBODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 YORK AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7945
Mailing Address - Country:US
Mailing Address - Phone:718-626-0670
Mailing Address - Fax:718-626-0694
Practice Address - Street 1:3016 30TH DR
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11102-1874
Practice Address - Country:US
Practice Address - Phone:718-626-0670
Practice Address - Fax:718-626-0694
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244985208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02956889Medicaid
KY64070725Medicaid
KY0068125Medicare ID - Type Unspecified
KY64070725Medicaid