Provider Demographics
NPI:1366403339
Name:SHREEDHAR, RAKESH (MD)
Entity type:Individual
Prefix:
First Name:RAKESH
Middle Name:
Last Name:SHREEDHAR
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 1:20 GRAND ST FL 3
Mailing Address - Street 2:CREDENTIALING MANAGER
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3906
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:10 LIBERTY SQUARE
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NY
Practice Address - Zip Code:10980
Practice Address - Country:US
Practice Address - Phone:845-942-0228
Practice Address - Fax:845-942-1519
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169924208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01143228Medicaid
E20410Medicare UPIN
21F781Medicare ID - Type Unspecified