Provider Demographics
NPI:1447612981
Name:SHAFA, JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SHAFA
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 1:1400 PELHAM PARKWAY SOUTH
Mailing Address - Street 2:BUILDING #1, ROOM 4N69
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:BUILDING 1, 4TH FLOOR ROOM 4N69
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-918-3612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1721542085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology