Provider Demographics
NPI:1477639615
Name:SHEVELEV, IRENE (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:SHEVELEV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 EAST FRANKLIN TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1515
Mailing Address - Country:US
Mailing Address - Phone:201-652-1888
Mailing Address - Fax:201-652-6485
Practice Address - Street 1:201 EAST FRANKLIN TURNPIKE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1515
Practice Address - Country:US
Practice Address - Phone:201-652-1888
Practice Address - Fax:201-652-6485
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04586100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0850306Medicaid