Provider Demographics
NPI:1538379599
Name:SHALLAT, JOHN E (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:SHALLAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1345 RXR PLZ FL 13
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-453-0435
Mailing Address - Fax:646-846-3283
Practice Address - Street 1:1930 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3328
Practice Address - Country:US
Practice Address - Phone:631-254-5900
Practice Address - Fax:631-392-0948
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2019-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY219990-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02322681Medicaid
NY679V31Medicare ID - Type Unspecified
NY02322681Medicaid