1356378434 NPI number — RAJAN S SHAH MD

Table of content: RAJAN S SHAH MD (NPI 1356378434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356378434 NPI number — RAJAN S SHAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
RAJAN
Provider Middle Name:
S
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:
1356378434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 FALCON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVINGSTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-642-0280
Provider Business Mailing Address Fax Number:
973-642-0047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-642-0280
Provider Business Practice Location Address Fax Number:
973-642-0047
Provider Enumeration Date:
06/26/2006

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: 207R00000X , with the licence number:  MA40413 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: MA40413 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0560901 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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