Provider Demographics
NPI:1487738829
Name:PATHARE, SHAILESH SURESH (MD)
Entity type:Individual
Prefix:
First Name:SHAILESH
Middle Name:SURESH
Last Name:PATHARE
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 1:565 JEWETT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2654
Mailing Address - Country:US
Mailing Address - Phone:718-701-6010
Mailing Address - Fax:718-447-7831
Practice Address - Street 1:565 JEWETT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2654
Practice Address - Country:US
Practice Address - Phone:718-701-6010
Practice Address - Fax:718-447-7831
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205677-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0012J1OtherEMPIRE BC BS
NY173446OtherELDERPLAN
NY205677OtherHIP
NY355618300OtherUS DEPT OF LABOR
NYP1883750OtherOXFORD
NY02006962Medicaid
NY4C4399OtherPHS/HEALTHNET
NY8799893OtherGHI
NYP00006210OtherRAILROAD MEDICARE
NYP1883750OtherOXFORD