Provider Demographics
NPI:1609822360
Name:SHAH, KETAN D (DPM)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:D
Last Name:SHAH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9234 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5312
Mailing Address - Country:US
Mailing Address - Phone:201-868-2400
Mailing Address - Fax:201-868-2014
Practice Address - Street 1:9234 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5312
Practice Address - Country:US
Practice Address - Phone:201-868-2400
Practice Address - Fax:201-868-2014
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00270100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8882401Medicaid
NJ059062Medicare ID - Type Unspecified
NJ8882401Medicaid