Provider Demographics
NPI:1790847903
Name:SHAH, SMITA (MB,BS)
Entity Type:Individual
Prefix:DR
First Name:SMITA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MB,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:741 NORTHFIELD AVE STE 201
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1104
Practice Address - Country:US
Practice Address - Phone:973-379-5181
Practice Address - Fax:973-379-6181
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA45882207RP1001X
NJ25MA04588200207RS0012X
CAC168318207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0898805Medicaid
SH155007Medicare ID - Type Unspecified
NJ0898805Medicaid
NJ155007CM4Medicare PIN