Provider Demographics
NPI:1992073787
Name:PRIYA, SHANMUKHA (MD)
Entity type:Individual
Prefix:DR
First Name:SHANMUKHA
Middle Name:
Last Name:PRIYA
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 1:1336 SUN AVENUE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2640
Mailing Address - Country:US
Mailing Address - Phone:718-210-8378
Mailing Address - Fax:888-858-2068
Practice Address - Street 1:20B MEACHAM AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2654
Practice Address - Country:US
Practice Address - Phone:516-270-2569
Practice Address - Fax:516-706-6026
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265894208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03506883Medicaid