Provider Demographics
NPI:1477787315
Name:SHAJI, JACKSON (DO)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:
Last Name:SHAJI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 N BROADWAY
Mailing Address - Street 2:STE 207
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1310
Mailing Address - Country:US
Mailing Address - Phone:914-969-3635
Mailing Address - Fax:
Practice Address - Street 1:970 N BROADWAY
Practice Address - Street 2:STE 207
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1310
Practice Address - Country:US
Practice Address - Phone:914-969-3635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273982207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology