Provider Demographics
NPI:1154650190
Name:SHAH, BHAIRAVI SAGAR (RD)
Entity Type:Individual
Prefix:MRS
First Name:BHAIRAVI
Middle Name:SAGAR
Last Name:SHAH
Suffix:
Gender:F
Credentials:RD
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 178
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-0178
Mailing Address - Country:US
Mailing Address - Phone:973-371-3166
Mailing Address - Fax:973-371-3266
Practice Address - Street 1:40 UNION AVE STE 101
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3290
Practice Address - Country:US
Practice Address - Phone:973-371-3166
Practice Address - Fax:973-371-3266
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ972682133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered