Provider Demographics
NPI:1043421811
Name:REZVANIAN, SHIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:
Last Name:REZVANIAN
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:PO BOX 6801
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-0801
Mailing Address - Country:US
Mailing Address - Phone:908-387-6611
Mailing Address - Fax:
Practice Address - Street 1:185 ROSEBERRY ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1690
Practice Address - Country:US
Practice Address - Phone:908-835-1910
Practice Address - Fax:908-835-1886
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJN-A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ218847Medicaid
NJ218847Medicaid