Provider Demographics
NPI:1316059033
Name:SHAH, MADHAVI (MD)
Entity type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 BROAD STREET
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-743-1392
Mailing Address - Fax:973-743-3707
Practice Address - Street 1:199 BROAD STREET
Practice Address - Street 2:SUITE 1B
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-743-1392
Practice Address - Fax:973-743-3707
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA041063208000000X
NJMAO410632080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1045504Medicaid
NJ1045504Medicaid