Basic Information
Provider Information | |||||||||
NPI: | 1538571997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAH | ||||||||
FirstName: | JAY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 739 | ||||||||
Address2: |   | ||||||||
City: | VESTAL | ||||||||
State: | NY | ||||||||
PostalCode: | 138510739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 96 CAMPUS DR STE 1 | ||||||||
Address2: |   | ||||||||
City: | SCARBOROUGH | ||||||||
State: | ME | ||||||||
PostalCode: | 040747164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078859905 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2014 | ||||||||
LastUpdateDate: | 09/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD21629 | ME | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 21709 | NH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 287267 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 21709 | NH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 287267 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | MD21629 | ME | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.