Provider Demographics
NPI:1720044308
Name:PANDEY, SHIVENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVENDRA
Middle Name:
Last Name:PANDEY
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 1:19 FULLING MILL LN
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1278
Mailing Address - Country:US
Mailing Address - Phone:732-840-0880
Mailing Address - Fax:732-840-3499
Practice Address - Street 1:204 JACK MARTIN BLVD
Practice Address - Street 2:SUITE C3
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7770
Practice Address - Country:US
Practice Address - Phone:732-840-0880
Practice Address - Fax:732-840-3499
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-24
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06669100207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8177201Medicaid
NJ8177201Medicaid
NJ036265Medicare ID - Type Unspecified