1578734562 NPI number — MR. SUDHIR R SHAH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578734562 NPI number — MR. SUDHIR R SHAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
SUDHIR
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1578734562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 AGATHA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDISON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08817-2251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-287-3969
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 ARTHUR KILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10309-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-984-8172
Provider Business Practice Location Address Fax Number:
718-984-9434
Provider Enumeration Date:
03/18/2008

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: 183500000X , with the licence number:  036299-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: RI 01901400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036299-1 . This is a "NY STATE BOARD OF PHARMAC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: RI 01901400 . This is a "NJ BOARD OF PHARMACY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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