Provider Demographics
NPI:1497784094
Name:SHAH, HETAL S (MD)
Entity Type:Individual
Prefix:MR
First Name:HETAL
Middle Name:S
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 1:777 ROUTE 70 EAST
Mailing Address - Street 2:SUITE G-101
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2345
Mailing Address - Country:US
Mailing Address - Phone:856-983-9939
Mailing Address - Fax:856-983-9936
Practice Address - Street 1:777 ROUTE 70 EAST
Practice Address - Street 2:SUTIE G-101
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2345
Practice Address - Country:US
Practice Address - Phone:856-983-9939
Practice Address - Fax:856-983-9936
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA075031207Q00000X
NJ25MA07503100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ240537OtherAMERIGROUP
NJ7876554OtherAETNA
NJ0045047Medicaid
NJI11632Medicare UPIN
NJ240537OtherAMERIGROUP