Basic Information
| Provider Information | |||||||||
| NPI: | 1366403339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHREEDHAR | ||||||||
| FirstName: | RAKESH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST FL 3 | ||||||||
| Address2: | CREDENTIALING MANAGER | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873906 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 LIBERTY SQUARE | ||||||||
| Address2: | |||||||||
| City: | STONY POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459420228 | ||||||||
| FaxNumber: | 8459421519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 169924 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01143228 | 05 | NY | MEDICAID |