Provider Demographics
NPI:1326059320
Name:SHAH, PRADIP S (MD)
Entity Type:Individual
Prefix:
First Name:PRADIP
Middle Name:S
Last Name:SHAH
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 1:57 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4631
Mailing Address - Country:US
Mailing Address - Phone:973-716-0052
Mailing Address - Fax:
Practice Address - Street 1:459 PASSAIC AVE
Practice Address - Street 2:CRANE'S MILL - OAK HEALTH CENTER
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7457
Practice Address - Country:US
Practice Address - Phone:973-276-3026
Practice Address - Fax:973-276-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA062084207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7190701Medicaid
NJ7190701Medicaid
NJ698297Medicare ID - Type Unspecified