Provider Demographics
NPI:1427025980
Name:SHOSHILOS, ANNA (DO)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:SHOSHILOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 GRAND AVE
Mailing Address - Street 2:SUITE: 202
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4152
Mailing Address - Country:US
Mailing Address - Phone:201-871-4040
Mailing Address - Fax:201-871-7326
Practice Address - Street 1:420 GRAND AVE
Practice Address - Street 2:SUITE: 202
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4152
Practice Address - Country:US
Practice Address - Phone:201-871-4040
Practice Address - Fax:201-871-7326
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB69060207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223450311OtherTAX ID/FHC/166 LYONS AVE
NJ223680351OtherTAX ID/201LYONS AVENUE
NJ8184801Medicaid
NJ223680351OtherTAX ID/201LYONS AVENUE
NJH02459Medicare UPIN