Provider Demographics
NPI:1114587730
Name:SHAH, SHIVANI (DO)
Entity type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-7133
Mailing Address - Fax:856-856-3557
Practice Address - Street 1:2225 E EVESHAM RD STE 102
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1557
Practice Address - Country:US
Practice Address - Phone:856-355-7133
Practice Address - Fax:856-355-7134
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019306207R00000X
NJ25MB12401300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1031333Medicaid