Provider Demographics
NPI:1538233853
Name:SHAFFER, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1023
Mailing Address - Country:US
Mailing Address - Phone:917-913-0649
Mailing Address - Fax:929-577-5002
Practice Address - Street 1:14 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1023
Practice Address - Country:US
Practice Address - Phone:917-913-0649
Practice Address - Fax:929-577-5002
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00712469Medicaid
NY994P24Medicare ID - Type Unspecified
NY480005968Medicare PIN
NYT32213Medicare UPIN
NY00712469Medicaid