Provider Demographics
NPI:1093745077
Name:KARRY MOHANRAO, SHAILENDER (MD)
Entity Type:Individual
Prefix:
First Name:SHAILENDER
Middle Name:
Last Name:KARRY MOHANRAO
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 1:2115 MILLBURN AVE
Mailing Address - Street 2:STE L2
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3714
Mailing Address - Country:US
Mailing Address - Phone:973-275-1322
Mailing Address - Fax:973-900-8453
Practice Address - Street 1:2115 MILLBURN AVE
Practice Address - Street 2:SUITE L2
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3724
Practice Address - Country:US
Practice Address - Phone:973-275-1322
Practice Address - Fax:973-900-8917
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08279900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0155641Medicaid