Provider Demographics
NPI:1053406959
Name:SHAH, KETKI S (MD)
Entity type:Individual
Prefix:
First Name:KETKI
Middle Name:S
Last Name:SHAH
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 1:591 MILL RUN
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1754
Mailing Address - Country:US
Mailing Address - Phone:201-612-7732
Mailing Address - Fax:201-612-3692
Practice Address - Street 1:1276 FULTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3402
Practice Address - Country:US
Practice Address - Phone:718-901-8445
Practice Address - Fax:718-901-6490
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1739952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
47H542Medicare ID - Type Unspecified
NYF52334Medicare UPIN