Provider Demographics
NPI:1639384548
Name:DANIEL, SHAJI (MD)
Entity Type:Individual
Prefix:
First Name:SHAJI
Middle Name:
Last Name:DANIEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WASON AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1179
Mailing Address - Country:US
Mailing Address - Phone:413-733-9666
Mailing Address - Fax:413-750-3432
Practice Address - Street 1:100 WASON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1381
Practice Address - Country:US
Practice Address - Phone:413-733-9666
Practice Address - Fax:413-750-3432
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT046979207RN0300X
MA237483207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2161826Medicaid
MA2161826Medicaid