Provider Demographics
NPI:1114158755
Name:SHAH, SHRUTI A (MD)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:A
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 1:225 STATE ROUTE 35 STE 102B
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5933
Mailing Address - Country:US
Mailing Address - Phone:732-665-6492
Mailing Address - Fax:
Practice Address - Street 1:225 STATE ROUTE 35 STE 102B
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-5933
Practice Address - Country:US
Practice Address - Phone:732-665-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08317800207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00953302OtherRR MCR PTAN
NJP00953311OtherRR MCR PTAN
NJ0209015Medicaid
NJP00953311OtherRR MCR PTAN
NJ197785CDYMedicare PIN
NJ162511A01Medicare PIN