1912969379 NPI number — DR. MATTHEW SHAHBANDI MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912969379 NPI number — DR. MATTHEW SHAHBANDI MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

SHAHBANDI

Provider First Name:

MATTHEW

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1912969379

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/10/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1 DIAMOND HILL RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BERKELEY HEIGHTS

Provider Business Mailing Address State Name:

NJ

Provider Business Mailing Address Postal Code:

07922-2104

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

908-273-4300

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1515 BROAD ST STE B120

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BLOOMFIELD

Provider Business Practice Location Address State Name:

NJ

Provider Business Practice Location Address Postal Code:

07003-3059

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

973-873-7000

Provider Business Practice Location Address Fax Number:

973-743-8943

Provider Enumeration Date:

04/03/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208800000X , with the licence number:  MA76499 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208800000X , with the licence number: 25MA07649900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 3K4036 . This is a "HEALTHNET#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 8J4761 . This is a "EMPIRE BCBS (WAYNE)" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: P3011050 . This is a "OXFORD#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 2425466000 . This is a "AMERIHEALTH#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 7291254 . This is a "AETNA PPO#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 0124890 . This is a "GHI PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 1323475 . This is a "AETNA HMO#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 398325 . This is a "WELLCARE#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 8J4751 . This is a "EMPIRE BCBS (CLIFTON)" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 8J4752 . This is a "EMPIRE BCBS (W. PATERSON)" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".