1023081775 NPI number — RAJ D SHETH MD

Table of content: RAJ D SHETH MD (NPI 1023081775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023081775 NPI number — RAJ D SHETH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHETH
Provider First Name:
RAJ
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023081775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT DEPT
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19732-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-651-6212
Provider Business Mailing Address Fax Number:
302-651-4945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 CHILDREN'S WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-390-3600
Provider Business Practice Location Address Fax Number:
904-390-3422
Provider Enumeration Date:
02/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  39298 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0402X , with the licence number: ME102097 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0400X , with the licence number: ME102097 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 32380900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".