1730413550 NPI number — SHIVENDRA PANDEY MD PC

Table of content: (NPI 1730413550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730413550 NPI number — SHIVENDRA PANDEY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIVENDRA PANDEY MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1730413550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 FULLING MILL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLTS NECK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07722-1278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-223-0008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2640 HIGHWAY 70
Provider Second Line Business Practice Location Address:
SUITE 101B BUILDING 12
Provider Business Practice Location Address City Name:
MANASQUAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08736-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-223-0008
Provider Business Practice Location Address Fax Number:
732-223-8020
Provider Enumeration Date:
09/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PANDEY
Authorized Official First Name:
SHIVENDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
732-735-5455

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  MA66691 , 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: 8177201 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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