Provider Demographics
NPI:1467493718
Name:SHAH, KEKUL B (MD)
Entity Type:Individual
Prefix:
First Name:KEKUL
Middle Name:B
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 1:4 PRINCESS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2322
Mailing Address - Country:US
Mailing Address - Phone:609-896-1414
Mailing Address - Fax:609-896-2982
Practice Address - Street 1:4 PRINCESS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2322
Practice Address - Country:US
Practice Address - Phone:609-896-1414
Practice Address - Fax:609-896-2982
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07781300207W00000X
PAMD 424214207W00000X
WI44604-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H72087Medicare UPIN
PA083582GQPMedicare ID - Type Unspecified
NJ083624AW0Medicare ID - Type Unspecified