Provider Demographics
NPI:1053404749
Name:SHAMIM, KAUSAR (MD)
Entity type:Individual
Prefix:
First Name:KAUSAR
Middle Name:
Last Name:SHAMIM
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 1:1329 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3211
Mailing Address - Country:US
Mailing Address - Phone:718-337-6800
Mailing Address - Fax:
Practice Address - Street 1:1329 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3211
Practice Address - Country:US
Practice Address - Phone:718-337-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198807-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6514UPMedicare PIN
NYG01974Medicare UPIN