Provider Demographics
NPI:1205389772
Name:SHAH, KIMI SUDHIR
Entity Type:Individual
Prefix:MS
First Name:KIMI
Middle Name:SUDHIR
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CLARA MAASS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3550
Mailing Address - Country:US
Mailing Address - Phone:973-450-2448
Mailing Address - Fax:
Practice Address - Street 1:137 HADDENFIELD RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3907
Practice Address - Country:US
Practice Address - Phone:973-510-3809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00657600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily