Provider Demographics
NPI:1154429959
Name:SHAHAMAT, MORTEZA (MD)
Entity type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:SHAHAMAT
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 1:400 FRANKLIN TPKE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430
Mailing Address - Country:US
Mailing Address - Phone:201-995-1005
Mailing Address - Fax:201-995-1007
Practice Address - Street 1:400 FRANKLIN TPKE
Practice Address - Street 2:SUITE 104
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430
Practice Address - Country:US
Practice Address - Phone:201-995-1005
Practice Address - Fax:201-995-1007
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA53340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
459516OtherAETNA
NJ501700901Medicaid
BP257OtherOXFORD HEALTH PLANS
F15211Medicare UPIN
NJ501700901Medicaid