Provider Demographics
NPI:1164533659
Name:NAGENDRA, SHAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAN
Middle Name:M
Last Name:NAGENDRA
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 1:246 BARKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-3136
Mailing Address - Country:US
Mailing Address - Phone:862-899-7531
Mailing Address - Fax:973-685-7370
Practice Address - Street 1:246 BARKLEY AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3136
Practice Address - Country:US
Practice Address - Phone:862-899-7531
Practice Address - Fax:973-685-7370
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03001300174400000X
NY1420502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty