Provider Demographics
NPI:1003152265
Name:SHAH, VIDISHA (MPT)
Entity Type:Individual
Prefix:
First Name:VIDISHA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1400
Mailing Address - Country:US
Mailing Address - Phone:626-202-3596
Mailing Address - Fax:
Practice Address - Street 1:610 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1400
Practice Address - Country:US
Practice Address - Phone:212-227-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035781225100000X
NJ40QA01599200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist