Provider Demographics
NPI:1306347984
Name:SHAH, SIDDHARTH
Entity type:Individual
Prefix:
First Name:SIDDHARTH
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 PRESIDENTIAL BLVD
Mailing Address - Street 2:APT# 1119
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131
Mailing Address - Country:US
Mailing Address - Phone:732-725-2323
Mailing Address - Fax:
Practice Address - Street 1:4000 PRESIDENTIAL BLVD APT 1119
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1721
Practice Address - Country:US
Practice Address - Phone:732-725-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129082242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist