Provider Demographics
NPI:1629206875
Name:SHETAL MANSURIA MD LLC
Entity Type:Organization
Organization Name:SHETAL MANSURIA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHETAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANSURIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-294-2212
Mailing Address - Street 1:PO BOX 2107
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-7707
Mailing Address - Country:US
Mailing Address - Phone:973-535-3800
Mailing Address - Fax:973-535-3808
Practice Address - Street 1:22 OLD SHORT HILLS RD
Practice Address - Street 2:SUITE 213
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5604
Practice Address - Country:US
Practice Address - Phone:973-535-3800
Practice Address - Fax:973-535-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA71413207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ064937OtherMEDICARE, TYPE UNSPECIFIED
NJ064937OtherMEDICARE, TYPE UNSPECIFIED