Basic Information
| Provider Information | |||||||||
| NPI: | 1609033703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDAR | ||||||||
| FirstName: | SHIVANAND | ||||||||
| MiddleName: | SHANKAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3450 WAYNE AVE | ||||||||
| Address2: | APT#12H | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474317779 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 E 210TH ST | ||||||||
| Address2: | MONTEFIORE MEDICAL CENTER | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187412440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2008 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 266896 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0202X | 266896 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.