Provider Demographics
NPI:1407896251
Name:SHAH, SIMKI (OD)
Entity Type:Individual
Prefix:DR
First Name:SIMKI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-2820
Mailing Address - Country:US
Mailing Address - Phone:201-444-8277
Mailing Address - Fax:201-444-8849
Practice Address - Street 1:1005 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-2820
Practice Address - Country:US
Practice Address - Phone:201-444-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00592000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU97280Medicare UPIN
NJ086636Medicare ID - Type Unspecified