Provider Demographics
NPI:1124050570
Name:SHAH, SUKETU (MD)
Entity type:Individual
Prefix:
First Name:SUKETU
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BRANT AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1540
Mailing Address - Country:US
Mailing Address - Phone:732-382-0091
Mailing Address - Fax:732-382-8570
Practice Address - Street 1:4 PROGRESS ST
Practice Address - Street 2:SUITE B6
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1199
Practice Address - Country:US
Practice Address - Phone:908-222-2658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08095100207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism